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Author of " Studies in Human and Comparative Pathology," 
"Instinct and Health," etc., etc. Clinical Professor of 
Medicine, New York Polyclinic, late Lecturer in 
Comparative Pathology, London Medical Grad- 
uates College and University of Buffalo 

Cambri&0e t 



Published November IQOQ 


I. The Body-Republic and its Defense 1 

II. Our Legacy of Health : the Power of Heredity 

in the Prevention of Disease 31 

III. The Physiognpmy of Disease: what a Doctor 

can tell from Appearances 55 

IV. Colds and how to catch Them 83 

V. Adenoids, or Mouth-Breathing: their Cause 

and their Consequences 103 

VI. Tuberculosis, a Scotched Snake. I 123 

VII. Tuberculosis, a Scotched Snake, n 140 

VIII. The Unchecked Great Scourge: Pneumonia 174 

IX. The Natural History of Typhoid Fever 198 

X. Diphtheria: the Modern Moloch 222 

XI. The Herods of Our Day: Scarlet Fever, 

Measles, and Whooping- Cough 243 

XII. Appendicitis, or Nature's Remnant Sale 267 


XIII. Malaria: the Pestilence that walketh in Dark- 

ness; the greatest Foe of the Pioneer 289 

XIV. Rheumatism: what it Is, and particularly 

what it Is n't 311 

XV. Germ-Foes that follow the Knife, or Death 

under the Finger-Nail 331 

XVI. Cancer, or Treason in the Body-State 350 

XVII. Headache: the most useful Pain in the World 367 

XVIII. Nerves and Nervousness 387 

XIX. Mental Influence in Disease, or how the Mind 

affects the Body 411 

Index 439 






r I THE human body as a mechanism is far from per- 
_1_ feet. It can be beaten or surpassed at almost 
every point by some product of the machine-shop or 
some animal. It does almost nothing perfectly or with 
absolute precision. As Huxley most unexpectedly 
remarked a score of years ago, " If a manufacturer of 
optical instruments were to hand us for laboratory use 
an instrument so full of defects and imperfections as 
the human eye, we should promptly decline to accept 
it and return it to him. But," as he went on to say, 
" while the eye is inaccurate as a microscope, imperfect 
as a telescope, crude as a photographic camera, it is all 
of these in one." In other words, like the body, while it 
does nothing accurately and perfectly, it does a dozen 
different things well enough for practical purposes. It 
has the crowning merit, which overbalances all these 
minor defects, of being able to adapt itself to almost 
every conceivable change of circumstances. 

This is the keynote of the surviving power of the 
human species. It is not enough that the body should 
be prepared to do good work under ordinary conditions, 


but it must be capable, if needs be, of meeting extraor- 
dinary ones. It is' not enough for the body to be able 
to take care of itself, and preserve a fair degree of effi- 
ciency in health, under what might be termed favorable 
or average circumstances, but it must also be prepared 
to protect itself and regain its balance in disease. 

The human automobile in its million-year endurance- 
run has had to learn to become self -repairing ; and well 
has it learned its lesson. Not only, in the language of the 
old saw, is there ' ' a remedy for every evil under the sun," 
but in at least eight cases out of ten that remedy will be 
found within the body itself. Generations ago this self- 
balancing, self-repairing power was recognized by the 
more thoughtful fathers in medicine and even dignified 
by a name in their pompous Latinity the vis medica- 
trix natures, the healing power of nature. 

In the new conception of disease, our drugs, our 
tonics, our prescriptions and treatments, are simply 
means of rousing this force into activity, assisting its 
operations, or removing obstacles in its way. This 
remedial power does not imply any gift of prophecy on 
nature's part, nor is it proof of design, or beneficent 
intention. It is rather one of those blind reactions to 
certain stimuli, tending to restore the balance of the 
organism, much as that interesting, new scientific toy, 
the gyroscope car, will respond to pressure exerted or 
weight placed upon one side by rising on that side, 
instead of tipping over. Let the onslaught of disease 
be sufficiently violent and unexpected, and nature will 
fail to respond in any way. 

Moreover, we and our intelligences are a product of 


nature and a part of her remedial powers. So there is 
nothing in the slightest degree irrational or inconsistent 
in our attempting to assist in the process. 

However, a great, broad, consoling and fundamental 
fact remains : that in a vast majority of diseases which 
attack humanity, under ninety per cent of the unfa- 
vorable influences which affect us, nature will effect a 
cure if not too much interfered with. As the old proverb 
has it, " A man at forty is either a fool or a physician " ; 
and nature is a good deal over forty and has never been 
accused of lacking intelligence. 

In the first place, nature must have acquired a fair 
knowledge of practical medicine, or at least a good 
working basis for it, from the fact that the body, in the 
natural processes of growth and activity, is perpetually 
manufacturing poisons for its own tissues. 

In this age of sanitary reform, we are painfully aware 
that the most frequent causes of human disease are the 
accumulations about us of the waste products of our 
own kitchens, barns, and factories. The "bad air" 
which we hear so frequently and justly denounced as a 
cause of disease, is air which we have ourselves polluted. 
This same process has been going on within the body 
for millions of years. No sooner did three or four cells 
begin to cling together, to form an organism, a body, 
than the waste products of the cells in the interior of the 
group began to form a source of danger for the others. 
If some means of getting rid of these could not be de- 
vised, the group would destroy itself, and the experi- 
ment of cooperation, of colony-formation, of organiza- 
tion in fact, would be a failure. 


Hence, at a very early period we find the development 
of the rudiments of systems of body-sewerage, pro- 
viding for the escape of waste poisons through the 
food-tube, through the kidneys, through the gills and 
lungs, through the sweat glands of the skin. So that 
when the body is confronted by actual disease, it has all 
ready to its hand a remarkably effective and resource- 
ful system of sanitary appliances sewer-flushing, 
garbage-burning, filtration. In fact, this is precisely 
what it does when attacked by poisons from without : 
it neutralizes and eliminates them by the same meth- 
ods which it has been practicing for millions of years 
against poisons from within. 

Take, for instance, such a painfully familiar and 
unheroic episode as an attack of colic. It makes little 
difference whether the attack is due to the swallowing 
of some mineral poison, like lead or arsenic, or the ir- 
ritating juice of some poisonous plant or herb, or to the 
every-day accident of including in the menu some 
article of diet which was beginning to spoil or decay, 
and which contained the bacteria of putrefaction or 
their poisonous products. The reaction of defense is 
practically the same, varying only with the violence and 
the character of the poison. If the dose of poisonous 
substances be unusually large or virulent, nature may 
short-circuit the whole attack by causing the outraged 
stomach to reject its contents. The power of " playing 
Jonah" is a wonderful safety-valve. 

If the poison be not sufficiently irritating thus to 
short-circuit its own career, it may get on into the 
intestines before the body thoroughly wakes up to its 


presence. This part of the food-tube being naturally 
geared to discharge its contents downward, the simplest 
and easiest thing is to turn in a hurry call and cut down 
the normal schedule from hours to minutes, with the 
familiar result of an acute diarrhoea. 

Both vomiting and purging are defensive actions on 
nature's part, remedies instead of diseases. Yet we are 
continually regarding and treating them as if they were 
diseases in themselves. Nothing could be more irra- 
tional than to stop a diarrhoea before it has accom- 
plished its purpose. Intelligent physicians now assist 
it instead of trying to check it in its early stages ; and 
paradoxical as it may sound, laxatives are often the 
best means of stopping it. It is only the excess of this 
form of nature's house-cleaning which needs to be 
checked. Many of the popular Colic Cures, Pain- 
Relievers, and "Summer Cordials" contain opium 
which, while it relieves the pain and stops the discharge, 
simply locks up in the system the very poisons which it 
was trying to get rid of. Laxatives, intestinal antisep- 
tics, and bowel irrigations have almost taken the place 
of opiates in the treatment of these conditions in modern 
medicine. We try to help nature instead of thwarting 

Supposing that the poison be of more insidious form, 
a germ or a ptomaine, for instance, which slips past 
these outer " firing-out " defenses of the food-tube and 
arouses no suspicion of its presence until it has been 
partially digested and absorbed into the blood. Again, 
resourceful nature is ready with another line of de- 
fense. It was for a long time a puzzle why every drop 


of the blood containing food and its products absorbed 
from the alimentary food-canal had to be carried, often 
by a most roundabout course, to and through the liver, 
before it could reach any part of the general system. 
Here was the largest and most striking organ in the 
body, and it was as puzzling as it was large. We knew 
in some crude way that it " made blood," that it pre- 
pared the food-products for use by the body-cells, and 
that it secreted the bile; but this latter secretion had 
little real digestive value, and the other changes seemed 
hardly important enough to demand that every drop 
of the blood coming from the food-tube should pass 
through this custom-house. Now, however, we know 
that in addition to its other actions, the liver is a great 
poison-sponge or toxin-filter, for straining out of the 
blood poisonous or injurious materials absorbed from 
the food, and converting them into harmless substances. 
It is astonishing what a quantity of these poisons, 
whether from the food or from germs swallowed with 
it, the liver is capable of dealing with destroying 
them, converting them, and acting as an absolute bar- 
rier to their passage into the general system. But 
sometimes it is overwhelmed by appalling odds ; some 
of the invaders slip through its lines into the general 
circulation, producing headache, backache, fever, and 
a "dark-brown taste in the mouth"; and, behold, we 
are bilious, and proceed to blame the poor liver. We 
used to pour in remedies to "stir it up," to "work on 
it" which was about as rational as whipping a horse 
when he is down, instead of cutting his harness or 
taking his load off. Nowadays we stop the supply of 


further food-poisons by stopping eating, assist nature 
in sweeping out or neutralizing the enemies that are 
still in the alimentary canal, flush the body with pure 
water, put it at rest and trust the liver. Biliousness 
is a sign of an overworked liver. If it was n't work- 
ing at all, we should n't be bilious : we should be dead, 
or in a state of collapse. 

Moral : Don't rush for some remedy with which to 
club into insensibility every symptom of disease as soon 
as it puts in an appearance. Give nature a little chance 
to show what she intends to do before attempting to 
stop her by dosing yourself with some pain-reliever 
or colic cure. Don't trdst her too blindly, for the best 
of things may become bad in extremes, and the body 
may become so panic-stricken as to keep on throwing 
overboard, not merely the poisons, but its necessary 
daily food, if the process be allowed to continue too long. 

This is where the doctor comes in. This is the point 
at which it takes brains to succeed in the treatment of 
disease to decide just how far nature knows what 
she is doing, even in her most violent expulsive methods, 
and is to be helped ; and just when she has lost her 
head, or got into a bad habit, and must be thwarted. 
This much we feel sure of, and it is one of the keynotes 
of the attitude of modern medicine, that a large ma- 
jority of the symptoms of disease are really nature's 
attempts to cure it. 

This is admirably shown in our modern treatment 
of fevers. These we now know to be due to the infec- 
tion of the body by more or less definitely recognized 
disease-germs or organisms. Fever is a complicated 


process, and we are still in the dark upon many points 
in regard to it, but we are coming more and more 
firmly to the conclusion that most of its symptoms are a 
part of, or at least incidents in, the fight of the body 
against the invading army. The flushed and reddened 
skin is due to the pumping of large quantities of blood 
through its mesh, in order that the poisons may be 
got rid of through the perspiration. The rapid pulse 
shows the vigor with which the heart is driving the 
blood around the body, to have its poisons neutral- 
ized in the liver, burned up in the lungs, poured out 
by the kidneys and the skin. The quickened breathing 
is the putting on of more blast in the lung poison- 
crematory. It is possible that even the rise of tempera- 
ture has an injurious effect upon the invading germs 
or assists the body in their destruction. 

In the past we have blindly fought all of these symp- 
toms. We shut our patients up in stove-heated rooms 
with windows absolutely closed, for fear that they 
would "catch cold." We took off the sheets and piled 
blankets upon the bed, setting a special watch to see 
that the wretched sufferer did not kick them off. We 
discouraged the drinking of water and insisted on all 
drinks that were taken being hot or lukewarm. Now- 
adays all this is changed. We throw all the windows 
wide-open, and even put our patients out of doors to 
sleep in the open air, whether it be typhoid, tuberculo- 
sis, or pneumonia; knowing that not only they will not 
"catch cold," but that, as their hurried breathing in- 
dicates, they need all the oxygen they can possibly get, 
to burn up the poison poured out in the lungs and from 


the skin. We encourage the patient to drink all the 
cool, pure water he will take, sometimes gallons in a 
day, knowing that his thirst is an indication for flush- 
ing and flooding all the great systems of the body 
sewers. Instead of smothering him in blankets, we 
put him into cold packs, or put him to soak in cool 

In short, we trust nature instead of defying her, co- 
operate with her in place of fighting her, and we 
have cut down the death-rate of most fevers fifty to 
seventy-five per cent already. Plenty of pure, cool 
water internally, externally, and eternally, rest, fresh 
air, and careful feeding, are the best febrifuges and 
antipyretics known to modern medicine. All others are 
frauds and simply smother a symptom without reliev- 
ing its cause, with the exception of quinine in malaria, 
mercury, and the various antitoxins in their appropriate 
diseases, which act directly upon the invading organism. 

Underneath all this storm and stress of the fever 
paroxysm, nature is quietly at work elaborating her 
antidote. In some marvelous fashion, which we do not 
even yet fully understand, the cells of the body are 
producing in ever-increasing quantities an antibody, 
or antitoxin, which will unite with the toxin or poison 
produced by the hostile germs and render it entirely 
harmless. By a curious paradox of the process, it does 
not kill the germs themselves. It may not even stop 
their further multiplication. Indeed, it utilizes part 
of their products in the formation of the antitoxin ; but 
it domesticates them, as it were turns them from 
dangerous enemies into harmless guests. 


The treaty between these germs and the body, how- 
ever, is only of the "most-favored-nation" class; for 
let these tamed and harmless friends of the family 
escape and enter the body of another human being, 
and they will attack it as virulently as ever. 

Now, where and how did nature ever succeed in 
getting the rehearsal and the practice necessary to 
build up such an extraordinary and complicated system 
of defense as this? Take your microscope and look 
at a drop of fluid from the mouth, the gums, the throat, 
the stomach, the bowels, and you will find it simply 
swarming with bacteria, bacilli, and cocci, each species 
of which numbers its billions. There are thirty- three 
species which inhabit the mouth and gums alone ! We 
are literally alive with them ; but most of them are ab- 
solutely harmless, and some of them probably slightly 
helpful in the processes of digestion. In fevers and 
infections the body merely applies to disease-germs the 
tricks which it has learned in domesticating these 
millions of harmless vegetable inhabitants. 

Still more curious there is a distinct parallel be- 
tween the method in which food-materials are split up 
and prepared for assimilation by the body, and the 
method adopted in breaking up and neutralizing the 
toxins of disease-germs. It is now known that poisons 
are formed in the process of digesting and absorbing 
the simplest and most wholesome foods; and the liver 
uses the skill which it has gained in dealing with these 
"natural poisons " in disposing of the toxins of germs. 

When a fever has run its course, as we now know 
nearly all infections do, within periods ranging from 


three or four days to as many weeks, it simply means 
that it has taken the liver and the other police-cells 
this length of time to handle the rioters and turn them 
into peaceable and law-abiding, even though not well- 
disposed citizens. In this process the forces of law and 
order can be materially helped by skillful and intelli- 
gent cooperation. But it takes brains to do it and avoid 
doing more harm than good. It requires far more in- 
telligence on the part of the doctor, the nurse, or the 
mother, skillfully to help nature than it did blindly to 
fight her. 

This is what doctors and nurses are trained for now- 
adays, and they are of 'use in the sickroom simply be- 
cause they have devoted more time and money to the 
study of these complicated processes than you have. 
Don't imagine that calling in the doctor is going to 
interfere with the natural course of the disease, or rob 
the patient of some chance he might have had of re- 
covering by himself. On the contrary, it will simply 
give nature and the constitution of the patient a better 
chance in the struggle, probably shorten it, and cer- 
tainly make it less painful and distressing. 

If these symptoms of the summer fevers and fluxes 
are indicative of nature's attempts to cure, those of the 
winter's coughs and colds are no less clearly so. As we 
walk down the streets, we see staring at us in large 
letters from a billboard, " Stop that Cough ! It is Killing 
you /" Yet few things could be more obvious to even 
the feeblest intelligence, than that this "killing" cough 
is simply an attempt on the part of the body to expel 
and get rid of irritating materials in the upper air- 


passages. As long as your larynx and windpipe are 
inflamed or tickled by disease-germs or other poisons, 
your body will do its best to get rid of them by cough- 
ing, or, if they swarm on the mucous membrane of the 
nose, by sneezing. To attempt to stop either coughing 
or sneezing without removing the cause is as irrational 
as putting out a switch-light without closing the switch. 
Though this, like other remedial processes, may go to 
extremes and interfere with sleep, or upset the stomach, 
within reasonable limits one of the best things to do 
when you have a cold is to cough. When patients with 
severe inflammations of the lungs become too weak or 
too deeply narcotized to cough, then attacks of suffo- 
cation from the accumulation of mucus in the air-tubes 
are likely to occur at any time. Young children who 
cannot cough properly, not having got the mechanism 
properly organized as yet, have much greater difficulty 
in keeping their bronchial tubes clear in bronchitis or 
pneumonia than have grown-ups. Most colds are in- 
fectious, like the fevers, and like them run their course, 
after which the cough will subside along with the rest 
of the symptoms. But simply stopping the cough won't 
hasten the recovery. Most popular "Cough-Cures" 
benumb the upper throat and stop the tickling; 
smother the symptoms without touching the cause. 
Many contain opium and thus load the system with 
two poisons instead of one. 

Lastly, in the realm of the nervous system, take that 
commonest of all ills that afflict humanity headache. 
Surely, this is not a curative symptom or a blessing in 
disguise, or, if so, it is exceedingly well disguised. And 


yet it unquestionably has a preventive purpose and 
meaning. Pain, wherever found, is nature's abrupt 
command, "Halt!" her imperative order to stop. 
When you have obeyed that command, you have taken 
the most important single step towards the cure. A 
headache always means something overwork, under- 
ventilation, eye-strain, underfeeding, infection. Some 
error is being committed, some bad physical habit is 
being dropped into. There are a dozen different reme- 
dies that will stop the pain, from opium and chloroform 
down to the coal-tar remedies (phenacetin, acetanilid, 
etc.) and the bromides. But not one of them "cures," 
in the sense of doings anything toward removing the 
cause. In fact, on the contrary they make the situation 
worse by enabling the sufferer to keep right on repeat- 
ing the bad habit, deprived of nature's warning of the 
harm that he is doing to himself. As the penalties of 
this continued law-breaking pile up, he requires larger 
and larger doses of the deadening drug, until finally he 
collapses, poisoned either by his own fatigue-products 
or by the drugs which he has been taking to deaden 
him against their effect. 

In fine, follow nature's hints whenever she gives 
them: treat pain by rest, infections by fresh air and 
cleanliness, the digestive disturbances by avoiding their 
cause and helping the food-tube to flush itself clean; 
keep the skin clean, the muscles hard, and the stomach 
well filled and you will avoid nine-tenths of the 
evils which threaten the race. 

The essence of disease consists, not in either the kind 
or the degree of the process concerned, but only in its 


relations to the general balance of activities of the or- 
ganism, to its " resulting in discomfort, inefficiency, or 
danger," as one of our best-known definitions has it. 
Disease, then, is not absolute, but purely relative ; there 
is no single tissue-change, no group even of changes 
or of symptoms, of which we can say, " This is essentially 
morbid, this is everywhere and at all times disease." 

Our attainment of any clear view of the essential 
nature of disease was for a long time hindered, and is 
even still to some degree clogged, by the standpoint 
from which we necessarily approached and still ap- 
proach it, not for the study of the disease itself, but for 
the relief of its urgent symptoms. Disease presents 
itself as an enemy to attack, in the concrete form of a 
patient to be cured ; and our best efforts were for cen- 
turies almost wasted in blind, and often irrational, 
attempts to remove symptoms in the shortest possible 
time, with the most powerful remedies at our disposal, 
often without any adequate knowledge whatever of the 
nature of the underlying condition whose symptoms 
we were combating, or any suspicion that these might 
be nature's means of relief, or that " haply we should 
be found to fight against God." There was sadly too 
much truth in Voltaire's bitter sneer, "Doctors pour 
drugs of which they know little, into bodies of which 
they know less"; and I fear the sting has not entirely 
gone out of it even in this day of grace. 

And yet, relative and non-essential as all our defi- 
nitions now recognize disease to be, it is far enough 
(God knows) from being a mere negative abstraction, 
a colorless "error by defect." It has a ghastly indi- 


viduality and deadly concreteness, nay, even a vindic- 
tive aggressiveness, which have both fascinated and 
terrorized the imagination of the race in all ages. From 
the days of " the angel of the pestilence" to the coming 
of the famine and the fever as unbidden guests into the 
tent of Minnehaha ; from " the pestilence that walketh 
in darkness" to the plague that still "stalks abroad" 
in even the prosaic columns of our daily press, there 
has been an irresistible impression, not merely of the 
positiveness, but even of the personality of disease. 
And no clear appreciation can possibly be had of our 
modern and rational conceptions of disease without at 
least a statement of the' earlier conceptions growing out 
of this personifying tendency. Absurd as it may seem 
now, it was the legitimate ancestor of modern patho- 
geny, and still holds well-nigh undisputed sway over 
the popular mind, and much more than could be de- 
sired over that of the profession. 

The earliest conception of disease of which we have 
any record is, of course, the familiar Demon Theory. 
This is simply a mental magnification of the painfully 
personal, and even vindictive, impression produced 
upon the mind of the savage by the ravages of disease. 
And certainly we of the profession would be the last to 
blame him for jumping to such a conclusion. Who 
that has seen a fellow being quivering and chattering in 
the chill-stage of a pernicious malarial seizure, or toss- 
ing and raving in the delirium of fever, or threatening 
to rupture his muscles and burst his eyes from their 
sockets in the convulsions of tetanus or uraemia, can 
wonder for a moment that the impression instinctively 


arose in the untutored mind of the Ojibwa that the 
sufferer was actually in the grasp, and trying to escape 
from the clutch, of some malicious but invisible power ? 
And from this conception the treatment logically fol- 
lowed. The spirits which possessed the patient, al- 
though invisible, were supposed to be of like passions 
with ourselves, and to be affected by very similar in- 
fluences; hence dances, terrific noises, beatings and 
shakings of the unfortunate victim, and the adminis- 
tration of bitter and nauseous messes, with the hope of 
disgusting the demon with his quarters, were the chief 
remedies resorted to. And while to-day such conceptions 
and their resultant methods are simply grounds for 
laughter, and we should probably resent the very sug- 
gestion that there was any connection whatever be- 
tween the Demon Theory and our present practice, yet, 
unfortunately for our pride, the latter is not only the 
direct lineal, historic descendant of the former, but 
bears still abundant traces of its lowly origin. It will, 
of course, be admitted at once that the ancestors of our 
profession, historically, the earliest physicians, were 
the priest, the Shaman, and the conjurer, who even to 
this day in certain tribes bear the suggestive name of 
"medicine men." Indeed, this grotesque individual 
was neither priest nor physician, but the common 
ancestor of both, and of the scientist as well. And, even 
if the history of this actual ancestry were unknown, 
there are scores of curious survivals in the medical 
practice of this century, even of to-day, which testify 
to the powerful influence of this conception. 
The extraordinary and disgraceful prevalence of 


bleeding scarcely fifty years ago, for instance; the 
murderous doses of calomel and other violent purges ; 
the indiscriminate use of powerful emetics like tartar 
emetic and ipecac; the universal practice of starving 
or " reducing" fevers by a diet of slops, were all obvious 
survivals of the expulsion-of-the-demon theory of treat- 
ment. Their chief virtue lay in their violence and re- 
pulsiveness. Even to-day the tendency to regard mere 
bitterness or distastefulness as a medicinal property 
in itself has not entirely died out. This is the chief claim 
of quassia, gentian, calumbo, and the "simple bitters" 
generally, to a place in our official lists of remedies. 
Even the great mineral-water fad, which continues to 
flourish so vigorously, owed its origin to the superstition 
that springs which bubbled or seethed were inhabited 
by spirits (of which the "troubling of the waters" in 
the Pool of Bethesda is a familiar illustration). The 
bubble and (in both senses) " infernal" taste gave them 
their reputation, the abundant use of pure spring water 
both internally and externally works the cure, assisted 
by the mountain air of the "Bad," and we sapiently 
ascribe the credit to the salts. Nine-tenths of our cells 
are still submarine organisms, and water is our greatest 

Then came the great "humoral" or "vital fluid" 
theory of disease which ruled during the Middle' Ages. 
According to this, all disease was due to the undue pre- 
dominance in the body of one of the four great vital 
fluids, the bile, the blood, the nervous "fluid," and 
the lymph, and must be treated by administering 
the remedy which will get rid of or counteract the excess 


of the particular vital fluid in the system. The principal 
traces of this belief are the superstition of the four 
" temperaments," the bilious, the sanguine, the nervous, 
and the lymphatic, and our pet term " biliousness," so 
useful in explaining any obscure condition. 

Last of all, in the fullness of time, and an incredi- 
bly late fullness it was, under the great pioneer 
Virchow, who died less than a decade ago, was de- 
veloped the great cellular theory, a theory which has 
done more to put disease upon a rational basis, to sub- 
stitute logic for fancy, and accurate reasoning for wild 
speculation, than almost any discovery since the dawn 
of history. Its keynote simply is, that every disturbance 
to which the body is liable can be ultimately traced to 
some disturbance or disease of the vital activities of the 
individual cells of which it is made up. The body is 
conceived of as a cell-state or cell-republic, composed of 
innumerable plastid citizens, and its government, both 
in health and disease, is emphatically a government 
"of the cells, by the cells, for the cells." At first these 
cell-units were regarded simply as geographic sections, 
as it were, sub-divisions of the tissues, bearing much 
the same relation to the whole body as the bricks of the 
wall do to the building, or, from a little broader view, 
as the Hessians of a given regiment to the entire army. 
They were merely the creatures of the organism as a 
whole, its servants who lived but to obey its commands 
and carry out its purposes, directed in purely arbitrary 
and despotic fashion by the lordly brain and nerve- 
ganglia, which again are directed by the mind, and that 
again by a still higher power. In fact, they were re- 


garded as, so to speak, individuals without personality, 
mere slaves and helots under the ganglion-oligarchy 
which was controlled by the tyrant mind, and he but 
the mouthpiece of one of the Olympians. But time has 
changed all that, and already the triumphs of demo- 
cracy have been as signal in biology as they have been 
in politics, and far more rapid. The sturdy little citi- 
zen-cells have steadily but surely fought their way to 
recognition as the controlling power of the entire body- 
politic, have forced the ganglion-oligarchy to admit that 
they are but delegates, and even the tyrant mind to 
concede that he rules by their sufferance alone. His 
power is mainly a vefb, and even that may be over- 
ruled by the usual two-thirds vote. 

In fact, if we dared to presume to criticise this mag- 
nificent theory of disease, we would simply say that it is 
not "cellular" enough, that it hardly as yet sufficiently 
recognizes the individuality, the independence, the 
power of initiative, of the single constituent cell. It is 
still a little too apt to assume, because a cell has donned 
a uniform and fallen into line with thousands of its 
fellows to form a tissue in most respects of somewhat 
lower rank than that originally possessed by it in its 
free condition, that it has therefore surrendered all of 
its rights and become a mere thing, a lever or a cog in 
the great machine. Nothing could be further from the 
truth, and I firmly believe that our clearest insight into 
and firmest grasp upon the problems of pathology will 
come from a recognition of the fact that, no matter how 
stereotyped, or toil-worn, or even degraded, the indi- 
vidual cells of any tissue may have become, they still 


retain most of the rights and privileges which they 
originally possessed in their free and imtrammeled 
amoeboid stage, just as in the industrial community of 
the world about us. And, although their industry in 
behalf of and devotion to the welfare of the entire 
organism is ever to be relied upon, and almost pathetic 
in its intensity, yet it has its limits, and when these have 
been transgressed they are as ready to " fight for their 
own hand," regardless of previous conventional alle- 
giance, as ever were any of their ancestors on seashore 
or rivulet-marge. And such rebellions are our most 
terrible disease-processes, cancer and sarcoma. More 
than this : while, perhaps, in the majority of cases the 
cell does yeoman service for the benefit of the body, in 
consideration of the rations and fuel issued to it by the 
latter, yet in many cases we have the curious, and at 
first sight almost humiliating, position of the cell ab- 
sorbing and digesting whatever is brought to it, and 
only turning over the surplus or waste to the body. 
It would almost seem as if our lordly Ego was living 
upon the waste-products, or leavings, of the cells lining 
its food-tube. 

Let us take a brief glance at the various specializations 
and trade developments, which have taken place in the 
different groups of cells, and see to what extent the 
profound modifications which many of them have 
undergone are consistent with their individuality and 
independence, and also whether such specialization 
can be paralleled by actually separate and independ- 
ent organisms existing in animal communities out- 
side of the body. First of all, because furthest from 


the type and degraded to the lowest level, we find the 
great masses of tissue welded together by lime-salts, 
which form the foundation masses, leverage-bars, and 
protection plates for the higher tissues of the body. 
Here the cells, in consideration of food, warmth, and 
protection guaranteed to themselves and their heirs for 
ever by the body-state, have, as it were, deliberately 
surrendered their rights of volition, of movement, and 
higher liberties generally, and transformed themselves 
into masses of inorganic material by soaking every 
thread of their tissues in lime-salts and burying them- 
selves in a marble tomb. Like Esau, they have sold their 
birthright for a mess 6f "potash," or rather lime; and 
if such a class or caste could be invented in the external 
industrial community, the labor problem and the ever- 
occurring puzzle of the unemployed would be much 
simplified. And yet, petrified and mummified as they 
have become, they are still emphatically alive, and 
upon the preservation of a fair degree of vigor in them 
depends entirely the strength and resisting power of 
the mass in which they are embedded, and of which 
they form scarcely a third. Destroy the vitality of its 
cells, and the rock-like bone will waste away before the 
attack of the body-fluids like soft sandstone under the 
elements. Shatter it, or twist it out of place, and it will 
promptly repair itself, and to a remarkable degree 
resume its original directions and proportions. 

So little is this form of change inconsistent with the 
preservation of individualism, that we actually find 
outside of the body an exactly similar process, occurring 
in individual and independent animals, in the familiar 


drama of coral-building. The coral polyp saturates it- 
self with the lime-salts of the sea-water, much as the 
bone-corpuscles with those of the blood and lymph, and 
thus protects itself in life and becomes the flying buttress 
of a continent in death. 

In the familiar connective-tissue, or "binding-stuff," 
we find a process similar in kind but differing in the 
degree, so to speak, of its degradation. 

The quivering responsiveness of the protoplasm of 
the amoeboid ancestral cell has transformed itself into 
tough, stringy bands and webs for the purpose of bind- 
ing together the more delicate tissues of the body. It 
has retained more of its rights and privileges, and con- 
sequently possesses a greater amount of both biological 
and pathological initiative. In many respects purely 
mechanical in its function, fastening the muscles to the 
bones, the bones to each other, giving toughness to the 
great skin-sheet, and swinging in hammock-like mesh 
the precious brain-cell or potent liver-lobule, it still 
possesses and exercises for the benefit of the body con- 
siderable powers of discretion and aggressive vital 
action. Through its activity chiefly is carried out that 
miracle of human physiology, the process of repair. 
By the transformation of its protoplasm the surplus 
food-materials of the times of plenty are stored away 
within its cell-wall against the time of stress. 

Whatever emergency may arise, nature, whatever 
other forces she may be unable to send to the rescue, can 
always depend upon the connective-tissues to meet it; 
and, of course, as everywhere the medal of honor has 
its reverse side, their power for evil is as distinguished 


as their power for good. From their ranks are re- 
cruited a whole army of those secessions from and re- 
bellions against the body at large the tumors, from 
the treacherous and deadly sarcoma, or " soft cancer," 
to the harmless fatty tumor, as well as the tubercle, 
the gumma of syphilis, the interstitial fibrosis of Bright's 
disease. They are the sturdy farmers and ever ready 
"minute-men" of the cell-republic, and we find their 
prototype and parallel in the external world, both in 
material structure and degree of vitality, in the well- 
known sponge and its colonies. 

Next in order, and, in fact, really forming a branch of 
the last, we find the great group of storage-tissues, the 
granaries or bankers of the body-politic, distinguished 
primarily, like the capitalist class elsewhere, by an 
inordinate appetite, not to say greed. They sweep into 
their interior all the food-materials which are not ab- 
solutely necessary for the performance of the vital func- 
tion of the other cells. These they form first into pro- 
toplasm, and then by a simple degenerative process it is 
transformed, "boiled down" as it were, into a yellow 
hydrocarbon which is capable of storage for practically 
an indefinite period. Not a very exalted function, and 
yet one of great importance to the welfare of the entire 
body, for, like the Jews of the Middle Ages, the fat- 
cells, possessing an extraordinary appetite for and 
faculty of acquiring surplus wealth in times of plenty, 
can easily be robbed of it and literally sucked dry in 
times of scarcity by any other body-cell which happens 
to need it, especially by the belligerent military class of 
muscle-cells. In fever or famine, fat is the first element 


of our body-mass to disappear ; so that Proudhon would 
seem to have some biological basis for his demand for 
the per capita division of the fortunes of millionaires. 
And yet, rid the fat-cell of the weight of his sordid gains, 
gaunt him down, as it were, like a hound for the wolf- 
trail, and he becomes at once an active and aggressive 
member of the binding-stuff group, ready for the repair 
of a wound or the barring out of a tubercle-bacillus. 

And this form of specialization has also its parallel 
outside of the body in one of the classes in a community 
of Mexican ants, whose most distinguishing feature is 
an enormously distended oesophagus, capable of con- 
taining nearly double the weight of the entire remainder 
of the body. They are neither soldiers nor laborers, 
but accompany the latter in their honey-gathering ex- 
cursions, and as the spoils are collected they are lite- 
rally packed full of the sweets by the workers. When 
distended to their utmost capacity they fall apparently 
into a semi-comatose condition, are carried into the 
ant-hill, and hung up by the hind legs in a specially 
prepared chamber, in which (we trust) enjoyable posi- 
tion and state they are left until their contents are 
needed for the purposes of the community, when they are 
waked up, compelled to disgorge, and resume their ordi- 
nary life activities until the next season's honey-gather- 
ing begins. It scarcely need be pointed out what an un- 
speakable boon to the easily discouraged and unlucky 
the introduction of such a class as this into the human 
industrial community would be, especially if this 
method of storage could be employed for certain liquids. 

Another most important class in the cell-community 


is the great group of the blood-corpuscles, which in 
some respects appear to maintain their independence 
and freedom to a greater degree than almost any other 
class which can be found in the body. While nearly all 
other cells have become packed or felted together so as 
to form a fixed and solid tissue, these still remain en- 
tirely free and unattached. They float at large in the 
blood-current, much as their original ancestor, the 
amoeba, did in the water of the stagnant ditch. And, 
curiously enough, the less numerous of the two great 
classes, the white, or leucocytes, are in appearance, 
structure, pseudopodic movements, and even method 
of engulfing food, almost exact replicas of their most 
primitive ancestor. 

There is absolutely no fixed means of communication 
between the blood-corpuscles and the rest of the body, 
not even by the tiniest branch of the great nerve- tele- 
graph system, and yet they are the most loyal and de- 
voted class among all the citizens of the cell-republic. 
They are called hither and thither partly by messenger- 
substances thrown into the blood, known as hor- 
mones, partly by the " smell of the battle afar off," 
the toxins of inflammation and infection as they pour 
through the blood. 

The red ones lose their nuclei, their individuality, in 
order to become sponges, capable of saturating them- 
selves with oxygen and carrying it to the gasping tissues. 
The white are the great mounted police, the sanitary 
patrol of the body. The moment that the alarm of in- 
jury is sounded in a part, all the vessels leading to it 
dilate, and their channels are crowded by swarms of the 


red and white hurrying to the scene. The major part 
of the activity of the red cells can be accounted for by 
the mechanism of the heart and blood-vessels. They are 
simply thrown there by the handful and the shovelful, 
as it were, like so many pebbles or bits of chalk. 

But the behavior of the white cells goes far beyond 
this. We are almost tempted to endow them with 
volition, though they are of course drawn or driven by 
chemical and physical attractions, like iron-filings by a 
magnet, or an acid by a base. Not only do all those 
normally circulating in the blood flowing through the 
injured part promptly stop and begin to scatter them- 
selves through the underbrush and attack the foe at 
close quarters, but, as has been shown by Cabot's 
studies in leucocytosis, the moment that the red flag of 
fever is hoisted, or the inflammation alarm is sounded, 
the leucocytes come rushing out from their feeding- 
grounds in the tissue-interspaces, in the lymph-chan- 
nels, in the great serous cavities, and pour themselves 
into the blood-stream, like minute-men leaving the 
plough and thronging the highways leading towards 
the frontier fortress which has been attacked. Arrived 
at the spot, if there be little of the pomp and pageantry 
of war in their movements, their practical devotion and 
heroism are simply unsurpassed anywhere, even in 
song and story. They never think of waiting for rein- 
forcements or for orders from headquarters. They 
know only one thing, and that is to fight; and when the 
body has brought them to the spot, it has done all that 
is needed, like the Turkish Government when once it 
has got its sturdy peasantry upon the battlefield : they 


have not even the sense to retreat. And whether they 
be present in tens, or in scores, or in millions, each one 
hurls himself upon the toxin or bacillus which stands 
directly in front of him. If he can destroy the bacillus 
and survive, so much the better; but if not, he will 
simply overwhelm him by the weight of his body-mass, 
and be swept on through the blood-stream into the great 
body-sewers, with the still living bacillus literally buried 
in his dead body. Like Arnold Winkelried, he will 
make his body a sheath for a score of the enemy's 
spears, so that his fellows can rush in through the gap 
that he has made. And it makes no difference whatever 
if the first ten or hundred or thousand are instantly 
mowed down by the bacillus or its deadly toxins, the 
rear ranks sweep forward without an instant's hesita- 
tion, and pour on in a living torrent, like the Zulu impis 
at Rorke's Drift, until the bacilli are battered down 
by the sheer impact of the bodies of their assailants, or 
smothered under the pile of their corpses, When this 
has happened, in the language of the old surgeon- 
philosophers, "suppuration is established," and the 
patient is saved. 

Or if, as often happens, an antitoxin is formed, 
which protects the whole body, this is largely built out 
of substances set free from the bodies of slain leucocytes. 
And the only thing that dims our vision to the wonder 
and beauty of this drama, is that it happens every day, 
and we term it prosaically "the process of repair," and 
expect it as a matter of course. Every wound-healing 
is worthy of an epic, if we could only look at it from the 
point of view of these citizens of our great cell-republic. 


And if we were to ask the question, "Upon what does 
their peculiar value to the body-politic depend?" we 
should find that it was largely the extent to which they 
retained their ancestral characteristics. They are born 
in the lymph-nodes, which are simply little islands of 
tissue of embryonic type, preserved in the body largely 
for the purpose of breeding this primitive type of cells. 
They are literally the Indian police, the scavengers, the 
Hibernians, as it were, of the entire body. They have 
the roving habits and fighting instincts of the savage. 
They cruise about continually through the waterways 
and marshes of the body, looking for trouble, and, like 
their Hibernian descendants, wherever they see a head 
they hit it. They are the incarnation of the fighting 
spirit of our ancestors, and if it were not for their re- 
tention of this characteristic in so high a degree, many 
classes of our fixed cells would not have been able to 
subside into such burgher-like habits. 

Although even here, as we shall see, it is only a ques- 
tion of quickness of response, for while the first bands 
of the enemy may be held at bay by the leucocyte 
cavalry, and a light attack repelled by their skirmish- 
line, yet when it comes to the heavy fighting of a fever- 
invasion, it is the slow but substantial burgher-like 
fixed cells of the body which form the real infantry 
masses of the campaign. And I believe that upon the 
proportional relation between these primitive and civil- 
ized cells of our body-politic will depend many of the 
singular differences, not only in degree but also in kind, 
in the immunity possessed by various individuals. 
While some surgeons and anatomists will show a tern- 


perature from the merest scratch, and yet either never 
develop any serious infection or display very high re- 
sisting power in the later stages, others, again, will 
stand forty slight inoculations with absolute impunity, 
and yet, when once the leucocyte-barrier is broken 
down, will make apparently little resistance to a fatal 
systemic infection. And this, of course, is only one of a 
score of ways in which the leucocytes literally pro 
patrin moriuntur. Our whole alimentary canal is con- 
tinually patrolled by their squadrons, poured into it by 
the tonsils above and Peyer's patches below ; if it were 
not for them we should probably be poisoned by the 
products of our own digestive processes. 

If, then, the cells of the body-republic retain so much 
of their independence and individuality in health, does 
it not seem highly probable that they do also in disease ? 
This is known to be the case already in many morbid 
processes, and their number is being added to every 
day. The normal activities of any cell carried to excess 
may constitute disease, by disturbing the balance of the 
organism. Nay, most disease-processes on careful 
examination are found to be at bottom vital, often 
normal to the cells concerned in them. The great 
normal divisions of labor are paralleled by the great 
processes of degeneration into fat, fibrous tissue, and 
bone or chalk. A vital chemical change which would be 
perfectly healthy in one tissue or organ, in another 
may be fatal. 

Ninety-nine times out of a hundred any group of 
cells acts loyally in the interests of the body ; once in a 
hundred some group acts against them, and for its own, 


and disease is the result. There is a perpetual struggle 
for survival going on between the different tissues and 
organs of the body. Like all other free competition, as 
a rule, it inures enormously to the benefit of the body- 
whole. Exceptionally, however, it fails to do so, and 
behold disease. This struggle and turmoil is not only 
necessary to life it is life. Out of the varying chances 
of its warfare is born that incessant ebb and flow of 
chemical change, that inability to reach an equilibrium, 
which we term "vitality." The course of life, like 
that of a flying express train, is not a perfectly straight 
line, but an oscillating series of concentric curves. 
Without these oscillations movement could not be. 
Exaggerate one of them unduly, or fail to rectify it by 
a rebound oscillation, and you have disease. 

Or it is like the children's game of shuttlecock. So 
long as the flying shuttle keeps moving in its restless 
course to and fro, life is. A single stop is death. The 
very same blow which, rightly placed, sends it like an 
arrow to the safe centre of the opposing racket, if it fall 
obliquely, or even with too great or too little force, drives 
it perilously wide of its mark. It can recover the safe 
track only by a sudden and often violent lunge of the 
opposing racket. The straight course is life, the tangent 
disease, the saving lunge recovery. 

One and the same force produces all. 

In the millions of tiny blows dealt every minute in 
our body-battle, what wonder if some go wide of the 



evil in things always bulks large in our imagi- 
-L nations. It is no mere coincidence that the earli- 
est gods of a race are invariably demons. Our first 
conception of the great forces of nature is that they are 
our enemies. This misconception is not only natural, 
but even necessary on, the sternest of physical bases. 
The old darky, Jim, in Huckleberry Finn, hit upon a 
profound and far-reaching truth when he replied in 
answer to Huck's question whether among all the signs 
and portents with which his mind was crammed like 
black cats and seeing the moon over your left shoulder 
and "harnts" some were not indications of good 
luck instead of all being of evil omen : 

" Mighty few an' dey ain't no use to a body. What 
fur you want to know when good luck 's a-comin'? 
Want to keep it off?" 

It is n't the good, either in the forces of nature or in 
our fellows, that keeps us watchful, but the evil. Hence 
our proneness to declare in all ages that evil is stronger 
than good and that "all men are liars." One injury 
done us by storm, by sunstroke, by lightning-flash, will 
make a more lasting impression upon our memories 
than a thousand benefits conferred by these same 
forces. Besides, evil has to be sharply looked out for 


and guarded against. Well enough can be safely let 

The conviction is steadily growing, among both 
physicians and biologists, that this attitude has caused 
a serious, if not vital, misconception of the influence of 
that great conservative and preservative force of na- 
ture heredity. We hear a great deal of hereditary 
disease, hereditary defect, hereditary insanity, but very 
little of hereditary powers of recovery, of inherited 
vigor, and the fact that ninety-nine and seven-tenths 
per cent of us are sane. 

One instance of hereditary defect, of inherited degen- 
eracy, fills us with horror and stirs us to move Heaven 
and earth to prevent another such. The inheritance of 
vigor, of healthfulness, and of sanity we placidly accept 
as a matter of course and bank upon it in our plans for 
the future, without so much as a thank you to the force 
that underlies it. 

When once we clear away these inherited misconcep- 
tions and look the facts of the situation squarely in the 
face, we find that heredity is at least ten times as potent 
and as frequently concerned in the transmission and 
securing of health and vigor as of disease and weakness ; 
that its influence on the perpetuation of bodily and 
mental defects has been enormously exaggerated and 
that there are exceedingly few hereditary diseases. 

It is not necessary for our present purpose to enter 
into a discussion of the innumerable theories of that 
inevitable tendency of like to beget like, of child to 
resemble parent, which we call heredity. One reference, 
however, may be permitted to the controversy that has 


divided the scientific world : whether acquired charac- 
ters, changes occurring during the lifetime of the in- 
dividual, can be inherited. Disease is nine times out of 
ten an acquired character ; hence, instead of the proba- 
bilities being that it would be inherited, the balance of 
evidence to date points in exactly the opposite direc- 
tion. The burden of proof as to the inheritance of 
disease is absolutely upon those who believe in its pos- 

Another fundamental fact which renders the inheri- 
tance of disease upon a priori grounds improbable and 
upon practical grounds obviously difficult, is that char- 
acters or peculiarities, m order to be inherited certainly 
for more than a few generations, must be beneficial 
and helpful in the struggle. A moment's reflection will 
show this to be mathematically necessary, in that any 
family or race which tended to inherit defects and in- 
jurious characters would rapidly go down in the strug- 
gle for survival and become extinct. An inherited dis- 
ease of any seriousness could not run for more than two 
or three generations in any family, simply for the reason 
that by the end of that time there would be no family 
left for it to run in. A slight defect or small peculiarity 
of undesirable character might run for a somewhat 
longer period, but even this would tend toward dis- 
appearance and elimination by the stern, selective 
influence of environment. 

Naturally, this great conservative tendency of na- 
ture has, like all other influences, "the defects of its 
virtues," as the French say. It has no gifts of prophecy, 
and in the process of handing down to successive gener- 


ations those mechanisms and powers which have been 
found useful in the long, stern struggle of the past, it 
will also hand down some which, by reason of changes 
in the environment, are not only no longer useful, but 
even injurious. As the new light of biology has been 
turned on the human body and its diseases, it has re- 
vealed so many of these " left-overs," or remnants in 
the body-machine some of most dramatic interest 
that they at first sight have done much to justify the 
popular belief in the malignant tendencies of heredity. 

Yet, broadly considered, the overwhelming majority 
of them should really be regarded as honorable scars, 
memorials of ancient victories, monuments to difficul- 
ties overcome, significant and encouraging indications 
of what our body-machine is still capable of accom- 
plishing in the way of further adjustment to conditions 
in the future. The really surprising thing is not their 
number, but the infrequency with which they give rise 
to serious trouble. 

The human automobile is not only astonishingly well 
built, with all the improvements that hundreds of thou- 
sands of generations of experience have been able to 
suggest, but it is self-repairing, self-cleaning, and self- 
improving. It never lets itself get out of date. If only 
given an adequate supply of fuel and water and not 
driven too hard, it will stand an astonishing amount of 
knocking about in all kinds of weather, repairing itself 
and recharging its batteries every night, supplying its 
own oil, its own paint and polish, and even regulating 
its own changes of gear, according to the nature of the 
work it has to do. Simply as an endurance racer it is the 


toughest and longest-winded thing on earth and can run 
down and tire out every paw, pad, or hoof that strikes 
the ground wolf, deer, horse, antelope, wild goat. 
This is only a sample of its toughness and resisting 
power all along the line. 

These wide powers of self-support and adjustment 
overbalance a hundred times any little remnant de- 
fects in its machinery or gearing. Easily ninety-nine 
per cent of all our troubles through life are due to in- 
evitable wear and tear, scarcity of food-fuel, of water, 
of rest, and external accidents injuries and infectious 
diseases. Still, it occasionally happens that these little 
defects may furnish the point of least resistance at 
which external stresses and strains will cause the 
machine to break down. They are often the things 
which prevent us from living and " going to pieces all at 
once, all at once and nothing fust, just as bubbles do 
when they bust," like the immortal One-Hoss Shay. 
It is just as well that they should, for, of all deaths to 
die, the loneliest and the most to be dreaded is that by 
extreme old age. 

These vestigia or remnants instances of appar- 
ently hidebound conservatism on nature's part are 
very much in the public eye at present, partly on ac- 
count of their novelty and of their exceptional and 
extraordinary character. Easily first among these 
trouble-breeding remnants is that famous, or rather 
notorious, scrap of intestine, the appendix vermiformis, 
an obvious survival from that peaceful, ancestral period 
when we were more largely herbivorous in our diet and 
required a longer and more complicated food-tube, with 


larger side pouches in the course of it, to dissolve and 
absorb our food. Its present utility is just about that of 
a grain of sand in the eye. Yet, considering that it is 
present in every human being born into the world, the 
really astonishing thing is not the frequency with which 
it causes trouble, but the surprisingly small amount of 
actual damage that arises from it. Never yet in even the 
most appendicitis-ridden community has it been found 
responsible for more than one half of one per cent of the 

Then there is that curious and by no means uncom- 
mon tendency for a loop of the intestine to escape from 
the abdominal cavity, which we call hernia. This is one 
of a fair-sized group of dangers clearly due to the as- 
sumption of the erect position and our incomplete ad- 
justment thereto. In the quadrupedal position this 
necessary weak spot a partial opening through the 
abdominal wall was developed in that region which 
was highest from the point of view of gravity and least 
exposed to strain. In the bipedal position it becomes 
lowest and most exposed ; hence the much greater fre- 
quency of hernia in the human species as compared 
with any of the animals. 

Another fragment, of the impertinence of whose pres- 
ence many of us have had painful proof, is the third or 
last molar, so absurdly misnamed the wisdom tooth. If 
there be any wisdom involved in its appearance it is of 
the sort characterized by William Allen White's deli- 
cious definition : " That type of ponderous folly of the 
middle-aged which we term * mature judgment.' ' ' The 
last is sometimes worst as well as best, and this belated 


remnant is not only the last to appear, but the first to 
disappear. In a considerable percentage of cases it is 
situated so far back in the jaw that there is no room for 
it to erupt properly, and it produces inflammatory dis- 
turbances and painful pressure upon the nerves of the 
face and the jaw. 

Even when it does appear it is often imperfectly 
developed, has fewer cusps and fewer roots than the 
other molars, is imperfectly covered with enamel and 
badly calcified. In no small percentage of cases it does 
not meet its fellow of the jaw below and hence is almost 
useless for purposes of mastication. But it comes in 
every child born into the world, simply because at an 
earlier day, when our jaws were longer to give our 
canine teeth the swing they needed as our chief weapons 
of defense there was plenty of room for it in the jaw 
and it was of some service to the organism. If the 
Indiana State Legislature would only pass a law pro- 
hibiting the eruption of wisdom teeth in future, and 
enforce it, it would save a large amount of suffering, 
inconvenience, and discomfort, with little appreciable 
lack of efficiency! 

In this list of admitted charges against heredity must 
also come the gall-bladder, that curious little pouch 
budded out from the bile ducts, which has so little 
known utility as compared with its possibility as a 
starting-point for inflammations, gall-stones, and 

Then there is that disfiguring facial defect, harelip, 
due to a failure of the three parts of which our upper 
jaw is built to unite properly, this triple construction 


of the jaw being an echo of ancestral fishlike and rep- 
tilian times when our jaws were built in five pieces to 
permit of wide distention in the act of swallowing our 
prey alive. All over the surface of the body are to be 
found innumerable little sebaceous glands originally 
intended to lubricate hairs, which have now atrophied 
and disappeared. These useless scraps, under various 
forms of irritation, both external and internal, become 
inflamed and give rise to pimples, acne, or "a bad 

And so the list might be drawn out to most impres- 
sive length. But this length would be no indication of 
its real importance, inasmuch as the vast majority of 
entries upon it would come under the head of patho- 
logical curiosities, or conditions which were chiefly 
interesting on account of their rareness and unusual 
character. With the exception of the appendix, the 
gall-bladder, and hernia, these vestigial conditions 
may be practically disregarded as factors in the death- 

In the main, when the fullest possible study and 
recognition have been made of all the traces of experi- 
mentation and even of ancient failure that are to be 
found in this Twentieth Century body-machine of 
ours, the resulting impression is one of enormously 
increased respect for and confidence in the machine 
and its capabilities. While they are of great interest 
as indicating what the past history and experiences of 
the engine have been, and of highest value as enabling 
us to interpret and even anticipate certain weak spots 
in its construction and joints in its armor, their most 


striking influence is in the direction of emphasizing 
the enormous elasticity and resourcefulness of the 

Not only has it met and survived all these difficulties, 
but it is continuing the selfsame processes to-day. So 
far as we are able to judge, it is as young and as adapt- 
able as it ever was, and just as ready to " with a frolic 
welcome greet the thunder and the sunshine" as it ever 
was in the dawn of history. 

These ancestral and experimental flaws, even when 
unrecognized and unguarded against, have probably 
not at any time been responsible for more than one or 
two per cent of the body's breakdowns ; while, on the 
other hand, every process with which it fights disease, 
every trick of strategy which it uses against invading 
organisms, every step in the process of repair after 
wounds or injury, is a trick which it has learned in its 
million-year battle with its surroundings. 

Take such a simple thing as the mere apparently 
blind habit possessed by the blood of coagulating as 
soon as it comes in contact with the edges of a cut or 
torn blood-vessel, and think what an enormous safe- 
guard this has been and is against the possibility of 
death by hemorrhage. So well is it developed and so 
rapidly does it act that it is practically impossible to 
bleed some animals to death by cutting across any 
vessel smaller than one of the great aortic trunks. 
The rapidity and toughness of the clotting, combined 
with the other ancestral tricks of lowering the blood 
pressure and weakening down the heart, are so im- 
mensely effective that a slash across the great artery of 


the thigh in the groin of a dog will be closed completely 
before he can bleed to death. So delicate and so pur- 
poseful is this adjustment that the blood will continue 
as fluid as milk for ten, twenty, forty, eighty years 
as long as it remains in contact with healthy blood- 
vessels. But the instant it is brought in contact with a 
broken or wounded piece of a vessel-wall, that instant 
it will begin to clot. So inevitable is this result that it 
gives rise to some of the sudden forms of death by 
bloodclot in the brain or lung (apoplexy, "stroke"), 
the clot having formed upon the roughened inner sur- 
face of the heart or of one of the blood-vessels and then 
floated into the brain or lung. 

Then take that matchless and ingenious process of 
the healing of wounds, whose wondrousness increases 
with every step that we take into the deeper details of 
its study. First, the quick outpouring and clotting of 
the blood after enough has escaped to wash most poi- 
sonous or offending substances out of the wound. This 
living, surgical cement, elastic, self-moulding, sooth- 
ing, not only plugs the cut or torn mouths of the 
blood-vessels, but fills the gap of the wound level with 
the surface. Here, by contact with the air and in com- 
bination with the hairs of the animal it forms a tough, 
firm, protective coating or scab, completely shutting out 
cold, heat, irritants, or infectious germs. 

Into the wedge-shaped, elastic clot which now fills 
the wound from bottom to top like jelly in a mould, 
the leucocytes or white blood-cells promptly migrate 
and convert it into a mesh of living cells. They are 
merely the cavalry and skirmishers of the repair 


brigade and are quickly followed by the heavy infantry 
of the line in the shape of cells born of the injured tis- 
sues on either side of the wound. These join hands 
across the gap, the engineer corps and the commissariat 
department move up promptly to their support in the 
form of little vein-construction switches, which bud 
out from the wounded blood-vessels. The clot is 
transformed into what we term granulation tissue and 
begins to organize. A few days later this granulation 
tissue begins to contract and pull the lips of the wound 
together. If the gap has not been too wide the wound 
will be completely closed, its lips and deeper parts 
drawn together in nearly perfect line, separated only by 
a thin scar on the surface with a vertical keel of scar 
tissue descending from it. If the lips cannot be drawn 
together and there be no surgical skill at hand to assist 
them with stitches or bandages, then the gap will be filled 
up by the fibrous transformation of this granulation 
tissue and a thick, heavy scar result. Meanwhile, the 
skin-cells of the surface have not been idle, but are bud- 
ding out on either side of the healing wound, pushing 
a little line of colonists forward across the raw surface. 
In longer or shorter time, according to the width of the 
gap, these two lines meet, and the site of our wound 
or the scar that it has left is perfectly coated over with 
a layer of healthy skin. This drama has occurred so 
many score of times in every one of us that custom has 
blinded our eyes to its ingenious perfection, but it took 
a million years to bring it to its present finish. 

It may be a healthy corrective to our overweening 
conceit to remind ourselves that, remarkable and valu- 


able as it is, it is a mere infant in arms compared to the 
superb powers of replacement and repair possessed by 
our more remote ancestors. Most invertebrates and 
many of the lowest two classes of backboned animals, 
the fishes and the amphibians, cannot merely stop up a 
rent, but renew an entire limb, fin, yes, even eye or 
head. Cut an earthworm in two and the rear half will 
grow a new head and the front half a new tail. It may 
even be cut in four or five segments, each of which will 
proceed to form a head at one end and a tail at the other. 
The lobster can regrow a complete gill and any number 
of claws or an eye. A salamander will reproduce a foot 
and part of a limb. Take out the crystalline lens in the 
eye of a salamander and the edge of the iris, or colored 
part of the eye, will grow another lens. Take out both 
the lens and the iris and the choroid coat of the eye will 
reproduce both. 

We are in the A, B, C class in powers of repair by 
comparison with the angleworm, the lobster, or the sala- 
mander. Yet we are not without gruesome echoes of 
this lost power of regeneration in that our whole brood 
of tumors, including the deadly cancer and sarcoma, are 
due to a strange resumption, on the part of some little 
knot of our body-cells, of the power of reproducing 
themselves or the organ in which they are situated, 
without any regard to the welfare of the rest of the body. 
Cancer is, in one sense, a throwing off of the allegiance 
to the body-state and a resumption of amphibian powers 
of independent growth on the part of certain groups 
of our body-cells literally, a "rebellion of the cells." 

These are but a handful of scores of instances that 


could be adduced, showing that the majority of the 
processes upon which we rely in combating disease and 
preserving life are the result of the hereditary experi- 
ences of our cells. Intelligent physicians are receding 
completely from that curiously warped and jaundiced 
view which led us to regard heredity chiefly as a factor 
in the production of disease. It was, perhaps, natural 
enough, since it was inevitably only its injurious, or, so 
to speak, malicious, effects which were brought to our 
attention to be corrected. But, just as in the growth of 
our ethnic religions it is Evil that is worshiped first as 
strongest and most aggressive, and the recognition of 
the greater power of good comes only at a later stage, 
so it has been in pathology. 

Not only do we regard heredity as a comparatively 
small and steadily receding factor in the production of 
disease, but we fully and frankly recognize it as the 
strongest and most important single force in its pre- 
vention. All our processes of repair, all the reactions 
of the body against the attack of accident or of disease, 
are hereditary endowments, worked out with infinite 
pains and labor through tens of thousands of genera- 
tions. The utmost that we can do with our drugs and 
remedies is to appeal to and rouse into action the great 
healing power of nature, the classic " Vis medicatrix 
Nature?" an incarnation of our past experiences 
handed down by heredity. Enormously valuable and 
important as are the services to human welfare, health, 
and happiness which can be rendered by the destruc- 
tion of the living external causes of disease and the 
prevention of contagion, our most permanent and sub- 


stantial victories are won by appealing to and increas- 
ing this long-descended and hard-won power of indi- 
vidual resistance. 

" But," says some one at once, " I thought there were 
a large number of hereditary diseases." Fifty years ago 
there were a score of such, twenty years ago the score 
had sunk to five or six. Now there is scarcely one left. 
There is no known disease which is directly inherited as 
such. There is scarcely even a disease in which we now 
regard heredity as playing a dominant or controlling 
part. Among the few diseases in which there is serious 
dispute as to this are tuberculosis, insanity, epilepsy, 
and cancer. 

Then there are diseases which for a long time puzzled 
us as to the possibility of their inheritance, but which 
have now resolved themselves clearly into instances of 
the fact that a mother who happens to contract an acute 
infectious disease of any sort may communicate that 
disease to the unborn child. If this occurs at an early 
stage of development the child will naturally be 
promptly killed. In fact, this is the almost invariable 
result in smallpox and yellow fever. If, on the other 
hand, development be further advanced or the infection 
be of a milder character, like scarlet fever or syphilis, 
the child may be born suffering with the disease or with 
the vims in its blood, which will cause the disease to 
develop within a few days after birth. This, however, 
is clearly not inheritance at all, but direct infection. 
We no longer use the term hereditary syphilis but have 
substituted for it the word congenital, which simply 
means that a child is born with the disease. 


There is no such thing as this disease extending 
"unto the third and fourth generation," like the wrath 
of Jehovah. One fact must, of course, be remembered, 
which has probably proved a source of confusion in the 
popular mind, and that is its extraordinary "long- 
windedness. " It takes not merely two or three weeks 
or months to develop its complete drama, but any- 
where from three to thirty years, so that it is possible 
for a child to be born with the taint in its blood and 
yet not exhibit to the non-expert eye any sign of the 
disease until its eighth, twelfth, or even fifteenth 

The case of tuberculosis is almost equally clear-cut. 
In all the thousands of post-mortem examinations 
which have been held upon newborn children and upon 
mothers dying in or shortly after childbirth, the number 
of instances of the actual transference of the bacilli of 
tuberculosis from mother to child could be counted 
upon the fingers of two hands. It is one of the rarest of 
pathologic curiosities and, for practical purposes, may 
be entirely disregarded. When tuberculosis appears in 
several members of a family, in eight cases out of ten 
it is due to direct infection from parents or older chil- 
dren. This is strikingly brought out in the admirable 
work done by the Associated Dispensaries for Tuber- 
culosis of the Charity Organization Society of New 

One of the first steps in advance which they took was 
to establish in connection with every clinic for tubercu- 
losis an attendant nurse, whose duty it was to visit the 
patients at their homes and advise and instruct them as 


to improvements in their methods of living, ventilation, 
food, and the prevention of infection. 

It was not long before these intelligent women began 
to bring back reports of other cases in the same family. 
Now the procedure is regularly adopted, whenever a 
case presents itself, of rounding up the remainder of the 
family group for examination, with the astounding re- 
sult that where a mother or father is tuberculous, from 
twenty to sixty per cent of the children will be found to 
be suffering from some form of the infection. Instances 
of three infected children out of five living in the same 
room with a tuberculous mother are actually on 

No one can practice long in any of our great climatic 
health resorts for tuberculosis, like Colorado or the 
Pacific Slope, without coming across scores of painful 
and distressing instances of children of tuberculous 
parents dying suddenly in convulsions from tuberculous 
meningitis, or by a wasting diarrhoea from tuberculo- 
sis of the bowels, or from a violent attack of distention. 
of the bowels due to tuberculous peritonitis. The favor- 
ite breeding-place of the tubercle bacillus is unfortu- 
nately in the home. 

On the other hand, while the vast majority of cases of 
so-called hereditary tuberculosis are due to direct infec- 
tion, and may be prevented by proper disposal of the 
sputum and other methods for avoiding contagion, there 
is probably a hereditary element in the spread of tuber- 
culosis to this degree : that, inasmuch as all of us have 
been exposed to the attack and invasion of the tubercle 
bacillus, not merely scores, but hundreds of times, and 


have been able to resist or throw off that attack without 
apparent injury, the development of an invasion of the 
tubercle bacillus sufficiently extensive to endanger life 
is, in nine cases out of ten, in itself a proof of lowered 
resisting power on the part of the patient. This may be, 
and often is, only temporary, due to overwork, under- 
feeding, overconfinement, or that form of gradual suffo- 
cation which we politely term inadequate ventilation. 

In a certain percentage of cases, however, it is due to 
a chronic lack of vigor and vitality ; a lowering of the 
whole systemic tone, which may have existed from 
birth. In that case it is hardly to be expected that 
such an individual, becoming a parent, will be able 
to transmit to his or her offspring more vigor than he 
originally possessed. It is therefore probable that the 
children of a considerable percentage of tuberculous 
parents would not possess the same degree of resisting 
power against tuberculosis, or any other infection, as 
the average individual. 

It is doubtful whether this factor of inherited lowered 
resistance plays any very important part in the propaga- 
tion of tuberculosis, partly because it is comparatively 
seldom that consumptive marries consumptive, and 
such tendencies to lowered vigor and vitality as may be 
transmitted by one parent will be neutralized by the 
other ; partly also because, by the superb and beneficent 
logic of nature, the pedigree of any disease is of the 
most mushroom and insignificant length, while the 
pedigree of health stretches back to the very dawn of 
time. In the struggle for dominance which takes place 
between the germ cells of the father and those of the 


mother, the chances are at least ten to one in favor of 
the old ancestral traits of vigor, of resisting power, and 
of survival. How deeply this idea is implanted in the 
convictions of the scientific world, the bitterly and 
widely debated biologic question whether acquired 
characters or peculiarities can under any circumstances 
be inherited clearly shows. Victory for the present 
rests with those who deny the possibility of such in- 
heritance, and disease is emphatically an acquired 

Truth here, as everywhere, probably lies between the 
extremes, and both biologists and the students of disease 
have arrived at practically the same working compro- 
mise, namely, that while no gross defect, such as a 
mutilation, nor definite disease factor, such as a germ, 
nor even a cancer, can possibly be inherited, yet, inas- 
much as the two cells, which by their development 
form the new individual, are nourished by the blood of 
the maternal body, influences which affect the nutri- 
tiousness or healthfulness of that blood may unfavor- 
ably influence the development of the offspring. 

Disease cannot be inherited any more than a mutilat- 
ing defect, but the results of both, in so far as they 
affect the nutrition of the offspring in the process of 
formation, may be transmitted, though to a very much 
smaller extent than we formerly believed. In the case 
of tuberculosis, if the mother, during the months that 
she is building up the body and framework of a child, 
is in a state of reduced or lowered nutrition on account 
of consumption or any other disease, or has her tissues 
saturated with the toxins of this disease, it is hardly to 


be expected that the development of the child will pro- 
ceed with the same perfection as it would under per- 
fectly normal maternal surroundings. 

However, even this influence is comparatively small ; 
for one of the most marvelous things in nature is the 
perfection of the barrier which she has erected between 
the child before birth and any injurious conditions 
which may occur in the body of the mother. Here pre- 
ference, so to speak, is given to the coming life, and 
whenever there is a contest for an adequate supply of 
nutrition, as, for instance, in cases of underfeeding or of 
famine, it is the mother who will suffer in her nutrition 
rather than the child. *The unborn child, biologically 
considered, feeds upon the best she has to offer, reject- 
ing all that is inferior, doing nothing and giving nothing 
in return. 

How perfectly the coming generation is protected 
under the most unfavorable circumstances we have 
been given a striking object-lesson in one family of 
the lower animals. In the effective crusade against 
tuberculosis in dairy cattle waged by the sanitary 
authorities in Denmark, it was early discovered that 
the greatest practical obstacle to the extermination of 
tuberculosis in cattle was the enormous financial 
sacrifice involved in killing all animals infected. The 
disease was at that time particularly rife among the 
high-bred Jersey, Holstein, and other milking breeds. 
It was determined as a working compromise to test the 
truth of the modern belief that tuberculosis was trans- 
mitted only by direct infection, by permitting the more 
valuable cows to be saved alive for breeding purposes. 


They were isolated from the rest of the herd and given 
the best of care and feeding. The moment that their 
calves were born they were removed from them alto- 
gether and brought up on the milk of perfectly healthy 
cows. The milk of the infected cows was either 
destroyed or sterilized and used for feeding pigs. 

The results were brilliantly successful. Scarcely one 
of the calves thus isolated developed tuberculosis in 
spite of their highly infected ancestry. And not only 
were they not inferior in vigor and perfection of type 
to the remainder of their breed, but some of them have 
since become prize-winners. The additional care and 
more abundant feeding that they received more than 
compensated for any problematic defect in their he- 

As to the heredity of cancer, all that can be said is that 
the burden of proof rests upon those who assert it. It is 
really curious how widespread the belief is that cancer 
" runs in families," and how exceedingly slender is the 
basis of evidence for such a belief. There are so many 
things that we do not know about cancer that any posi- 
tive statement of any kind would be unbecoming. It 
would be absurd to declare that a disease, of which the 
cause is still unknown, either is or is not inherited. And 
this is our position in regard to cancer. An overwhelm- 
ing majority of the evidence so far indicates that it is not 
a parasite ; if it were, of course, we could say positively 
that it is not inherited. Although we are getting a dis- 
couraging degree of familiarity with the process and 
clearly recognize that it consists chiefly in the sudden 
revolt or rebellion of some group of cells, a tendency 


which quite conceivably might be transmitted to future 
generations, yet it is highly improbable, on both biologi- 
cal and pathological grounds, that such is the case. If 
this rebellious tendency were transmitted we should at 
least have the right to expect that 'it would appear in the 
cells of the same organ or region of the body. It is a 
singular fact that in all the hundreds of cases in which 
cancer has appeared in the child of a cancerous parent 
it has almost invariably appeared in some different 
organ from that affected in the parent. 

For instance, cancer of the lip in the father may be 
followed by cancer of the liver in the son or daughter, 
while cancer of the breast in the mother will be fol- 
lowed by cancer of the lip in a son. Further than this, 
the percentage of instances in which cancer appears in 
more than one member of a family is decidedly small, 
considering the frequency of the disease. 

I took occasion to look into the matter carefully from 
a statistical point of view some ten or twelve years ago, 
and out of a collection of some fifty thousand cases of 
cancer less than six per cent were found to give any his- 
tory of cancer in the family. And this, of course, simply 
means that some one of the relatives of the patient had 
at one time developed the disease. 

In fact, the consensus of intelligent expert opinion 
upon the subject of heredity of cancer is, that though it 
may occur, we have comparatively little proof of the 
fact; that the percentage of cases in which there is 
cancer in the family is but little larger than might be 
expected on the doctrine of probabilities from- the aver- 
age distribution. Though possibly the offspring of a 


cancerous individual may display a slightly greater ten- 
dency toward the development of that strange, curious 
process of "autonomy" than the offspring of the aver 
age individual, this tendency is so small and occurs so 
infrequently as to be a factor of small practical import- 
ance in the propagation and spread of the disease. 

In insanity and epilepsy we have probably the last 
refuge and almost only valid instance of the old belief 
in the remorseless heredity of disease. But even here 
the part played by heredity is probably only a fraction 
of that which it is popularly, and even professionally, 
believed to play. It is, of course, obvious that diseases 
which tend quickly to destroy the life of the patient, 
especially those which kill or seriously cripple him 
before he has reached the age of reproduction, or pre- 
vent his long surviving that epoch, will not, for me- 
chanical reasons, become hereditary. The Black Death, 
or the cholera, for instance, could not " run in a family." 
Supposing that children were born with a special sus- 
ceptibility to this disease, there would obviously soon 
be no family left. 

The same is true in a lesser degree of milder or more 
chronic diseases. The family which was hereditarily 
predisposed to scarlet fever, measles, smallpox, or tuber- 
culosis would not last long, and in fact the whole pro- 
gress of civilization has been a continuous process of 
the weeding out of those who were most susceptible and 
the survival of those who were least so. 

But when we come to deal with certain conditions, 
fortunately rare, such as functional disturbances of the 
nervous system, which neither seriously unfit their pos- 


sessor for the struggle of life nor prevent him from 
reproducing his kind, then it becomes possible that a 
tendency to such disease may be transmitted through 
several successive generations. 

Such is the case with insanity, with epilepsy, with 
hemophilia, or " bleeders," and with certain rare and 
curious disturbances of the nervous system, such as the 
hereditary ataxias and "tics" of various sorts. How- 
ever, even here the only conditions on which these 
diseases can continue to run in a family for more than 
one or two generations is either that they shall be mild 
in form or that only a comparatively small percentage 
of the total family shall be affected by them. If, for 
instance, two-thirds, one-half, or even a third of the 
descendants of a mentally unsound individual were to 
become insane, it would only need a few generations for 
that family to be crushed to the wall. 

While the descendants of insane persons are distinctly 
more liable to become insane than the rest of the com- 
munity, yet, on account of their fewness, this tendency 
probably does not account for more than a small frac- 
tion of the total insanity. We should, by all means, 
prevent the marriage of the insane and discourage that 
of their children, and the development of any well- 
defined form of insanity should act at once, ipso facto, 
as a ground and cause of divorce. 

But the consoling fact remains that even of such 
children, providing, of course, as usually happens, that 
the other parent husband or wife is sound and 
sane, not more than ten or fifteen per cent would 
probably become insane. In other words, insanity is 


acquired and the result of individual stress and strain 
at least five times as frequently as it is inherited. We 
have absolutely no rational or statistical basis for gloomy 
predictions that, at present 'rates, within a couple of 
centuries more, we shall all be shut up in asylums with 
nobody left to support us and pay the taxes. The 
apparent increase of insanity of recent decades is prob- 
ably only "on paper," due to better registration. 

To put it very roughly, probably ninety-eight per 
cent of us are so born, thanks to heredity, that the pos- 
sibility of our becoming insane, even under the severest 
stress, is almost infinitesimal. Of the two per cent born 
with this taint, this possible tendency to mental unbal- 
ance, only about one-tenth now become completely 
insane, 1 and this percentage might be greatly diminished 
by general sanitary improvements. Our alienists now 
claim that, by checking the reproduction of the obvi- 
ously unstable, and careful hygienic treatment and 
training of the predisposed two per cent, insanity is 
almost as preventable as tuberculosis. 

In fine, from all the broad field of pathology, the 
mists of tradition which have dimmed the fair name 
and reputation of heredity are slowly but surely lifting, 
until we now behold it, not as our worst enemy, but as 
our best friend in the prevention of disease and the 
upbuilding of the race. 

1 The proportion of registered insane in civilized countries to-day 
ranges from two to three per 1000 of the population. 



IT is our pride that medicine, from an art, and a 
pretty black one at that, originally, is becoming a 
science. And the most powerful factor in this devel- 
opment, its indispensable basis, in fact, has been the 
invention of instruments of precision the micro- 
scope, the fever thermometer, the stethoscope, the oph- 
thalmoscope, the test-tube, the culture medium, the 
triumphs of the bacteriologist and of the chemist. 
Any man who makes a final diagnosis in a serious case 
without resorting to some or all of these means is re- 
garded and justly as careless and derelict in his 
duty to his patient. 

At the same time, priceless and indispensable as are 
these laboratory methods of investigation, they should 
not be allowed to make us too scornful and neglectful 
of the evidence gained by the direct use of ourfive senses. 
We should still avail ourselves of every particle of in- 
formation that can be gained by the trained eye, the 
educated ear, the expert touch, the tactus eruditus 
of the medical classics, and even the sense of smell. 
There is, in fact, a general complaint among the older 
members of the profession that the rising generation 
is being trained to neglect and even despise the direct 
evidence of the senses, and to accept no fact as a fact 


unless it has been seen through the microscope or 
demonstrated by a reaction in the test-tube. As one of 
our keenest observers and most philosophic thinkers 
expressed it a few months ago : 

"I fear that certain physicians on their rounds are 
most careful to take with them their stethoscope, their 
thermometer, their hemoglobin papers, their sphygmo- 
manometer, but leave their eyes and their brains at 

And it is certain that the art of sight diagnosis, 
which seems like half magic, possessed in such a won- 
derful degree by the older physicians of the passing 
and past generations, has been almost lost by the 

A healthful reaction has, however, set in ; and while 
we certainly do not love the Caesar of laboratory 
methods and accuracy the less, we are beginning to 
have a juster affection for the Rome of the rich harvest 
that may be gained from the careful, painstaking, de- 
tective-like exercise of our eye, ear, and hand. 

As a matter of fact, the conflict between the two 
methods is only apparent. Not only is each in its pro- 
per sphere indispensable, but they are enormously 
helpful one to the other. Instead of our being able to 
tell less by the careful, direct eye-and-hand examina- 
tion of our patients than the doctor of a century ago, 
we can tell three to five times as much. Signs that he 
could interpret only by the slow and painful method 
of two-thirds of a lifetime of plodding experience, or 
by occasional flashes of half-inspired insight, we are 
now able to interpret absolutely upon a physiological 


yes, a chemical basis from the revelations of the 
microscope, the test-tube, and the culture medium. 
His only way of determining the meaning of a particu- 
lar tint of the complexion, or line about the mouth, or 
eruption on the skin, was by slowly and laboriously 
accumulating a long series of similar cases in which 
that particular symptom was found always to occur, 
and deducing its meaning. Now, we simply take a drop 
of our patient's blood, a scraping from his throat, a 
portion of some one of his secretions, a little slice of 
a tumor or growth, submit them to direct examina- 
tion in the laboratory, and get a prompt and decisive 

The observant physician begins to gather informa- 
tion about a patient from the moment he enters the 
sick-room or the patient steps into his consulting- 
room; and the value of the information obtained in 
the first thirty seconds, before a word has been spoken, 
is sometimes astonishingly great. While no intelligent 
man would dream of depending upon this first coup 
d'ceil, "stroke of the eye" as the French so graphically 
call it, for his final diagnosis, or accept its findings until 
he had submitted them to the most ruthless cross-ex- 
amination with the stethoscope and in the laboratory, 
yet it will sometimes give him a clew of almost priceless 
value. It is positively uncanny to see the swift, intuitive 
manner in which an old, experienced, and thoughtful 
physician will grasp the probable nature of a case in 
one keen look at a patient. Often he can hardly ex- 
plain to you himself how he does it, what are the data 
that determine it ; yet not infrequently, three times out 


of five, your most elaborate and painstaking study of 
the case with all the modern methods will bring you to 
the same conclusion as that sensed within forty-five 
seconds by this keen-eyed old sleuth-hound of the 
fever trails. Time and again, in my interne days, have 
I gone the rounds of the wards or the out-patient de- 
partments with some kindly-faced, keen-eyed old 
Sherlock Holmes of the profession, and seen him point 
to a new case across the ward with the question : " When 
did that pneumonia come in?" or pick out a pain- 
drawn, ashy mask in the waiting line, with an abrupt, 
" Bring me that case of cancer of the stomach. He's 
in pain. I '11 take him first." 

And, in later years, I have had colleagues with whom 
it was positively painful to walk down a crowded street, 
from the gruesome habit that they had of picking out, 
and condemning to lingering deaths, the cases of can- 
cer, of Bright's disease, or of locomotor ataxia, that we 
happened to meet. Of course, they would be the first 
to admit that this was only what they would term a 
"long shot," a guess; but it was a guess based upon 
significant changes in the patient's countenance or gait, 
which their trained eye picked out at once, and it was 
surprising how often this snapshot diagnosis turned 
out to be correct. 

The first thing that a medical student has to learn 
is that appearances are not deceptive except to fools. 
Every line of the human figure, every proportion of a 
limb, every detail of size, shape, or relation in an organ, 
means something. Not a line upon any bone in the 
skeleton which was not made by the hand-grip or thumb- 


print of some muscle, tendon, or ligament; no bump 
or knuckle which is not a lever or hand-hold for the 
grip of some muscle; not a line or a curve or an 
opening in that Chinese puzzle, the skull, which 
was not made to protect the brain, to accommodate 
an eye, to transmit a blood- vessel, or to allow the escape 
of a nerve. Every minutest detail of structure means 
something to the man who will take the pains to puz- 
zle it out. And if this is true of the foundation struc- 
ture of the body, is it to be expected that the law ceases 
to run upon the surface ? 

Not a line, not a tint, not a hollow of that living pic- 
ture, the face, but means something, if we will take the 
time and labor to interpret it. Even coming events cast 
their shadows before upon that most exquisitely re- 
sponsive surface half mirror, half sensitive plate 
the human countenance. The place where the moving 
finger of disease writes its clearest and most unmis- 
takable message is the one to which we must naturally 
turn, the face ; not merely for the infantile tenth part 
of a reason which we often hear alleged, that it is the 
only part of the body, except the hand, which is ha- 
bitually exposed, and hence open to observation, but 
because here are grouped the indicators and registers 
of almost every important organ and system in the body. 

What, of course, originally made the face the face, 
and, for the matter of that, the head the head, was the 
intake opening of the food-canal, the mouth. Around 
this necessarily grouped themselves the outlook de- 
partments, the special senses, the nose, the eyes, and 
ears; while later, by an exceedingly clumsy device 


of nature, part of the mouth was split off for the intake 
of a new ventilating system. So that when we glance 
at the face we are looking first at the automatically 
controlled intake openings of the two most important 
systems in the body, the alimentary and the respiratory, 
whose muscles contract and relax, ripple in comfort or 
knot in agony, in response to every important change 
that takes place throughout the entire extent of both. 

Second, at the apertures of the two most important 
members of the outlook corps, the senses of sight and 
of smell. These are not only sharply alert to every ex- 
ternal indication of danger, but by a curious reversal, 
which we will consider more carefully later, reflect 
signals of distress or discomfort from within. Last, 
but not least, the translucent tissues, the semi-trans- 
parent skin, barely veiling the pulsating mesh of my- 
riad blood-vessels, is a superb color index, painting in 
vivid tints "yellow, and ashy pale, and hectic red" 
the living, ever changing, moving picture of the 
vigor of the life-centre, the blood-pump, and the rich- 
ness of its crimson stream. Small wonder that the 
shrewd advice of a veteran physician to the medical 
student should be : " The first step in the examination 
is to look at your patient ; the second is to look again, 
and the third to take another look at him ; and keep 
on looking all through the examination." 

It is no uncommon thing for an expert diagnostician 
deliberately to lead the patient into conversation upon 
some utterly irrelevant subjects, like the weather, the 
crops, or the incidents of his journey to the city, simply 
for the purpose of taking his mind off himself, putting 


him at his ease, and meanwhile quietly deciphering 
the unmistakable cuneiform inscription, often twice 
palimpsest, written by the finger of disease upon his 
face. It takes time and infinite pains. In no other 
realm does genius come nearer to Buffon's famous 
description, "the capacity for taking pains," but it is 
well worth the while. And with all our boasted and 
really marvelous progress in precise knowledge of dis- 
ease, accomplished through the microscope in the 
laboratory, it remains a fact of experience that so 
careful and so trustworthy is this face-picture when 
analyzed, that our best and most depended upon im- 
pressions as to the actual condition of patients, are 
still obtained from this source. Many and many a time 
have I heard the expression from a grizzled consultant 
in a desperate case, "Well, the last blood-count was 
better," or, "The fever is lower," or, "There is less 
albumen, but I don't like the look of him a bit"; 
and within twenty-four hours you might be called in 
haste to find your patient down with a hemorrhage, 
or in a fatal chill, or sinking into the last coma. 

It would really be difficult to say just what that care- 
ful and loving student of the genus humanum known 
as a doctor looks at first in the face of a patient. In- 
deed, he could probably hardly tell you himself, and 
after he has spent fifteen or twenty years at it, it has 
become such a second nature, such a matter of instinct 
with him, that he will often put together all the signs 
at once, note their relations, and come to a conclusion 
almost in the " stroke of an eye," as if by instinct, just 
as a weather-wise old salt will tell you by a single glance 


at the sky when and from what quarter a storm is 

I shall never forget the remark of my greatest and 
most revered teacher, when he called me into his con- 
sultation-room to show me a case of typical locomotor 
ataxia, gave me a brief but significant history, put the 
patient through his paces, and asked for a diagnosis. 
I hesitated, blundered through a number of further un- 
necessary questions, and finally stumbled upon it. 
After the patient had left the room, I, feeling rather 
proud of myself, expected his commendation, but I 
did n't get it. "My boy," he said, "you are not up to 
the mark yet. You should be able to recognize a dis- 
ease like that just as you know the face of an acquaint- 
ance on the street." A positive and full-blown diagno- 
sis of this sort can, of course, only be made in two or 
three cases out of ten. But the method is both logical 
and scientific, and will give information of priceless 
value in ninety-nine cases out of a hundred. 

Probably the first, if not the most important, char- 
acter that catches the physician's eye when it first falls 
upon a patient is his expression. This, of course, is a 
complex of a number of different markings, but chiefly 
determined by certain lines and alterations of position 
of the skin of the face, which give to it, as we frequently 
hear it expressed, an air of cheerfulness or depression, 
comfort or discomfort, hope or despair. These lines, 
whether temporary or permanent, are made by the 
contractions of certain muscles passing from one part 
of the skin to another or from the underlying bones to 
the skin. These are known in our anatomical text- 


books by the natural but absurd name of "muscles 
of expression." 

Their play, it is true, does make up about two-thirds 
of the wonderful shifting of relations, which makes the 
human countenance the most expressive thing in the 
world ; but their original business is something totally 
different. Primarily considered, they are solely for the 
purpose of opening or closing, contracting or expand- 
ing, the different orifices which, as we have seen, ap- 
pear upon the surface of the face. This naturally throws 
them into three great groups: those about and con- 
trolling the orifice of the alimentary canal, the mouth ; 
those surrounding th joint openings of the air-tube 
and organ of smell, and those surrounding the eyes. 

As there are some twenty-four pairs of these in an 
area only slightly greater than that of the outspread 
hand, and as they are capable of acting with every 
imaginable grade of vigor and in every possible com- 
bination, it can readily be seen what an infinite and 
complicated series of expressions or, in other words, 
indications of the state of affairs within those differ- 
ent orifices they are capable of. Only the barest 
and rudest outlines of their meaning and principles 
of interpretation can be attempted. To put it very 
roughly, the main underlying principle of interpretation 
is that we make our first instinctive judgment of the 
site of the disease from noting which of the" three great 
orifices is distorted furthest from its normal condition. 
Then by constructing a parallel upon the similarity 
or the difference of the lines about the other two open- 
ings, we get what a surveyor would call our " lines of 


triangulation," and by following these to their con- 
verging point can often arrive at a fairly accurate 

The greatest difficulty in the method, though at 
times our greatest help, is the extraordinary and inti- 
mate sympathy which exists between all three of these 
groups. If pain, no matter where located, once becomes 
intense enough, its manifestations will travel over the 
face-dial, overflowing the organ or system in which it 
occurs, and eyes, nostrils, and mouth will alike reveal 
its presence. Here, of course, is where our second great 
process, so well known in all clew-following, elimina- 
tion, comes in. 

A patient comes in with pain-lines written all over 
his face. To put it very roughly has he cancer of the 
stomach? Pneumonia? Brain tumor? If there be 
no play of the muscles distending and contracting the 
nostrils with each expiration, no increased rapidity of 
breathing, no gasp when a full breath is drawn, and 
no deep red fever blush on the cheeks, we mentally 
eliminate pneumonia. The absence of these nasal 
signs throws us back toward cancer or some other pain- 
ful affection of the alimentary canal. If the pain-lines 
about the mouth are of recent formation, and have not 
graved themselves into the furrows of the forehead 
above and between the eyebrows ; if the color, instead 
of ashy, be clear and red, we throw out cancer and think 
of colic, ulcer, hyperacidity, or some milder form of 
alimentary disease. 

If, on the other hand, the pain-lines are heaviest 
about the brows, the eyes, and the forehead, with only 


a sympathetic droop or twist of the corners of the 
mouth, if the nostrils are not at all distorted or too 
movable, if there is no fever flush and little wasting, 
and on turning to the eyes we find a difference between 
the pupils, or a wide distention or pin-point-like con- 
traction of both or a slight squint, the picture of brain 
tumor would rise in the mind. Once started upon any 
one of these clews, then a hundred other data would 
be quickly looked for and asked after, and ultimately, 
assisted by a thorough and exhaustive examination 
with the instruments of precision and the tests in the 
laboratory, a conclusion is arrived at. This, of course, 
is but the roughest and crudest outline suggestive of 
the method of procedure. 

Probably not more than once in three times will the 
first clew that we start on prove to be the right one; 
but the moment that we find this barred, we take up 
the next most probable, and in this manner hit upon 
the true scent. 

As to the cause and rationale of these pain-lines, only 
the barest outlines can be given. Take the mouth for 
an example. When all is going well in the alimentary 
canal, without pain, without hunger, and both absorp- 
tion of food and elimination of waste are proceeding 
normally, the tissues about the mouth, like those of 
the rest of the body, are apt to be plump and full ; the 
muscles which open the aperture, having fulfilled their 
duty and received their regular wages, are quietly at 
rest ; those that close the opening, having neither anti- 
cipation of an early call for the admission of necessary 
nutriment, nor an instinctive desire to shut out any- 


thing that may be indigestible or undesirable, are now 
in their normal condition of peaceful, moderate con- 
traction; the face has a comfortable, well-fed, whole- 
some look. On the other hand, let the digestive juices 
fail to do their duty properly, or the swarms of bacteria 
pets which we keep in our food-canals get beyond con- 
trol ; or if for any other reason the tissues be kept from 
getting their proper supply of nourishment from the 
food-canal, the state of affairs is quickly revealed in the 
mouth mirror. Those muscles which open the mouth, 
instead of resting peacefully in the consciousness of 
duty well done, are in a state of perpetual fidget, twitch- 
ing, pulling, wondering whether they ought not to open 
the portal for the entrance of new supplies of material, 
since the tissues are crying for food. 

As the strongest of these are those which pull the 
corners of the mouth outward and downward, the re- 
sultant expression is one of depression, with downward- 
curving angles to the mouth. The eyes, and even the 
nostrils, sympathetically follow suit, and we have that 
countenance which, by the cartoonist's well-known 
trick, can be produced by the alteration of one pair of 
lines, those at the angles of the mouth, turning a smiling 
countenance into a weeping one. .On the other hand, 
if all these processes of nutrition and absorption are 
proceeding as they should, they are accompanied by 
mild sensations of comfort which, although they no 
longer reach our consciousness, reveal themselves in 
the mouth-opening muscles, and they gently contract 
upward and outward, in pleasurable anticipation of 
the next intake, and we get the grin or the smile. 


If, on the other hand, these digestive disturbances be 
accompanied by pain, then another shading appears 
on our magic mirror, and that is a curious contraction 
of the mouth, with distortion of the lines surrounding 
it, so violent in some cases as positively to whiten the 
lips or produce lines of paleness along the course of the 
muscles. This is the set or twisted mouth of agony, 
and is due to a curious transference and reflex on this 
order: that inasmuch as the last food which entered 
the alimentary canal -seems to have caused this dis- 
turbance and pain, no more will be allowed to enter 
it at present under any conditions. And as our alimen- 
tary instincts are the most fundamental of all, by a due 
process of transference, mental agony calls into action 
this same set of muscles, to shut out any possible addi- 
tion to the agony already present. 

The lines of determination, similarly, about the 
mouth, are those of the individual who has the courage 
to say "No" to the tempting morsel when he does n't 
need it ; and the lines of weakness and irresolution are 
those of the nature which cannot resist either gastro- 
nomic or other temptation. Similarly, the well-known 
lines of disgust or of discontent about the corners of the 
mouth are the unconscious contractions accompanying 
nausea, and preparations to expel the offending morsel 
whether from stomach or mouth. 

If, on the other hand, our first glance shows us that 
the deepest pain-lines are those about the nostrils and 
upper lip, especially if the wings of the nostrils can be 
seen to dilate with each breath, and breathing be faster 
than normal, our clew points in the direction of some 


disease of the great organs above the diaphragm that 
is, the lungs or heart. 

Signs in this region might refer to either of these, for 
the reason that, although a sufficient intake of air is one 
of the necessary conditions of proper oxygenation, a 
free and abundant circulation of the blood through the 
air-cells is equally essential. In fact, that common 
phenomenon known as "shortness of breath" is more 
frequently due to disturbances of the heart and circula- 
tion than it is to the lungs, especially in patients who 
are able to be up and about. If, in addition to the dan- 
ger signal of the rise and fall of the nostrils with each 
breath, we have a pale, translucent skin, with a light, 
hectic flush showing just below the knife-like lower 
edge of the cheekbone, a widely open, shining eye, and 
a clustering abundance of hair of a glossiness border- 
ing on dampness, red lips slightly parted, showing the 
teeth between, a painfully strong suspicion of consump- 
tion would arise unbidden. 

This pathetic type of face has that fatal gift which 
the French clinicians, with their usual happiness of 
phrase, term La beauU dudiable. The eager eyes, di- 
lated nostrils, parted lips, give that weird air of exal- 
tation which, when it occurs, as it occasionally does 
in the dying, is interpreted as the result of glimpses 
into a spirit world. When to this is added the mild 
delirium of fever, when memories of happier days and 
of those who have passed before rise unbidden and 
babble themselves from the tongue, one can hardly 
wonder at this interpretation. 

The last group of lines to be noted is that about the 


eyes and forehead. These are less reliable than either 
of the other two, for the reason that they are so sym- 
pathetic as almost invariably to be present in addition, 
whenever the lower dial-plates of the face are disturbed. 
It is only when they appear alone that they are signifi- 
cant; then they may be interpreted as one of three 
things : first, and commonest, eye strain ; second, dis- 
ease in some part of the nervous system or muscular 
system, not connected with the organs of the chest or 
abdomen; and third, mental disturbances. 

This last relation, of course, makes them in many 
respects the least reliable of all the face indices, be- 
cause as is household knowledge they indicate 
mental conditions and operations, as well as bodily. 
"The wrinkled brow of thought," the "deep lines of 
perplexity," etc., are in the vocabulary of the grammar 
grades. They are, however, a valuable check upon the 
other two groups. They are not apt to be present in 
consumption and in other forms of serious disease, 
attended by fever, on account of the curious effect 
produced by the toxins of the disease,. which is often 
not only stimulating, but even of an exhilarating 
nature, or will produce a slight stupor or lethargy, 
such as is typical of typhoid. 

One of the most singular transformations in the sick- 
room, especially in serious disease marked by lethargy 
or stupor, is that in which the patient's countenance 
will appear like a sponged-off slate, so completely have 
the lines of worry and of thought been obliterated. 

One distinct value of the pain-lines about the eyes 
and brow is that you can often test their genuineness. 


Just engage your hypochondriac or hysterical patient 
in lively conversation; or, on the reverse principle, 
wound his vanity, so as to produce an outburst of tem- 
per, and see how the lines of undying agony will fade 
away and be replaced by the curves of amusement or 
by the straight-drawn brows of indignation. 

As with the painter, next to line comes color. Every 
one, of course, knows that a fresh, rosy color is usually 
associated with health, while a pale, sallow complex- 
ion suggests disease. But our color signals, while more 
vivid, are much less reliable and more apt to deceive 
than our line-markings. 

Surprising as it may sound, careful analyses have 
shown, first, that the kind of pigment present in the 
human skin of every race is absolutely one and the 
same. The only difference between the negro and the 
white man is that the negro has two or three times as 
much of it. Secondly, that every skin except that of the 
albino has a certain, and usually a considerable, amount 
of this pigment present in it. 

" The red hue of health " is even more apt to mis- 
lead us, because, being due to the abundance of blood 
in the meshes of the skin, many fevers, by increasing 
the rapidity of the heart-beat and dilating the vessels 
in the skin, give a ruddiness of hue equal to or in ex- 
cess of the normal. 

However, a little careful checking up will eliminate 
most of the possible mistakes and enable us to obtain 
information of the greatest value from color. For in- 
stance, if our patient be of Southern blood, or tanned 
from the seashore, the good red blood in his arteries is 


pretty safe to show through at the normal blush area 
on the cheeks ; or, failing that, through the translucent 
epithelium of the lips and gums. If, on the other hand, 
this yellow tint be due to the escape of broken-down 
blood-pigments into the tissues, or a damming up of 
the bile, and a similar escape of its coloring matter, as 
in jaundice, then we turn to the whites of the eyes, and 
if a similar, but more delicate, yellowish tint confronts 
us there, we know we have to deal with a severe form 
of anaemia or jaundice, according to the tint. In ex- 
treme cases of the latter, the mucous membrane of the 
lips and of the gums will even show a distinctly yellow- 
ish hue. The frightfuf color of yellow fever, and the 
yellow " death mask," which appears just before the 
end of several fatal forms of blood poisoning, is due to 
the tremendous breaking down of the red cells of the 
blood under the attack of the fever toxins, and their 
leaking out into the tissues. A similar process of a 
milder and less serious extent occurs in those tempo- 
rary anaemias of young girls, known for centuries past 
in the vernacular as " the green sickness." And a deli- 
cate lemon tint of this same origin, accompanied by a 
waxy pallor, is significant of the deadly, pernicious 
anaemia and the later stages of cancer. 

The most significant single thing about the red flush, 
supposed to be indicative of health, is its location. If 
this be the normal " blush area," about the middle of 
each cheek, which is one of nature's sexual orna- 
ments, placed, like a good advertisement, where it will 
attract most attention and add most beauty to the 
countenance, and it fades off gradually at the edges 


into the clear whiteness or brownness of the healthy 
skin, it is probably both healthy and genuine. If the 
work of either fever or of art, it will generally reveal 
itself as a base imitation. In eight cases out of ten of 
fever, the flush, instead of being confined to this defi- 
nite area, extends all over the face, even up to the 
roots of the hair. The eyes, instead of being clear and 
bright, are congested and heavy-lidded; and if with 
these you have an increased rapidity of respiration, and 
a general air of discomfort and unrest, you are fairly 
safe in making a diagnosis of fever. If the first touch 
of the tips of the fingers on the wrist shows a hot skin 
and a rapid pulse, the diagnosis is almost as certain as 
with the thermometer. 

Now for two of the instances in which it most com- 
monly puzzles us. The first of these is consumption ; 
for here the flush, both in position and in delicacy and 
gentle fading away at the proper margins, is an almost 
perfect imitation of health. It, however, usually ap- 
pears, not as the normal flush of health does, upon a 
plump and rounded cheek, but upon a hollow and 
wasted one. It rises somewhat higher upon the cheek- 
bones, throwing the latter out into ghastly prominence. 
The lips and the eyes will give us no clew, for the 
former are red from fever, and the latter are bright from 
the gentle, half-dreamy state produced by the toxins 
of the disease, the so-called " spes phthisica" the 
everlasting and pathetic hopefulness of the consump- 
tive. But here we call for help upon another of the fea- 
tures of disease the hand. If, instead of being cool, 
and elastic, this is either dry and hot, or clammy and 


damp, and feels as if you were grasping a handful of 
bones and nerves, and the finger-tips are clubbed and 
the nails curved like claws, then you have a strong 
prima facie case. 

The other color condition which is apt to puzzle 
us is that of the plump and comfortable middle-aged 
gentleman with a fine rosy color, but a watery eye and 
loose and puffy mouth, a wheezy respiration and ap- 
parent excess of adipose. Here the high color is often 
due to a paralytic distention of the blood-vessels of the 
face and neck, and an examination of his heart and 
blood-vessels shows that his prospects are anything 
but as rosy as his countenance. 

The varying expressions of the face of disease are 
by no means confined to the countenance. In fact, 
they extend to every portion of in Trilby's immortal 
phrase "the altogether." Disease can speak most 
eloquently through the hand, the carriage, the gait, 
and, in a way that the patient may be entirely uncon- 
scious of, the voice. These forms of expression are 
naturally not so frequent as those of the face, on ac- 
count of the extraordinary importance of the great 
systems whose clock-dials and indices form what we 
term the human countenance. But when they do occur 
they are fully as graphic and more definitely and dis- 
tinctively localizing. 

Next in importance to the face comes the hand, and 
volumes have been written upon this alone. Contain- 
ing, as it does, that throbbing little blood-tube, the 
radial artery, which has furnished us for centuries with 
one of our oldest and most reliable guides to health 


conditions, the pulse, it has played a most important 
part in surface diagnoses. To this day, in fact, Arabic 
and Turkish physicians in visiting their patients on 
the feminine side of the family are allowed to see no- 
thing of them except the hand, which is thrust through 
an opening in a curtain. How accurate their diagnoses 
are, based upon this slender clew, I should not like to 
aver, but a sharp observer might learn much even from 
this limited area. 

We have though, of course, in lesser degree all 
the color and line pictures with which we have been 
dealing upon the face. Though not an index of any 
special system, it has the great advantage of being our 
one approach to an indication of the general muscular 
tone of the body, as indicated both in its grasp and in 
the poses it assumes at rest. The patient with a limp 
and nerveless hand-clasp, whose hand is inclined to 
lie palm upward and open instead of palm downward 
and half -closed, is apt to be either seriously ill, or not 
in a position to make much of a fight against the attack 
of disease. 

The nails furnish one of our best indices of the color 
of the blood and condition of the circulation. Our 
best surface test of the vigor of the circulation is to 
press upon a nail, or the back of the finger just above 
it, until the blood is driven out of it, and when our 
thumb is removed from the whitened area to note 
the rapidity with which the red freshet of blood will 
rush back to reoccupy it. 

In the natural growth of the nail, traveling steadily 
outward from root to free edge, its tissues, at first opaque 


and whitish, and thus forming the little white crescent, 
or lunula, found at the base of most nails, gradually 
become more and more transparent, and hence pinker 
in color, from allowing the blood to show through. 
During a serious illness, the portion of the nail which 
is then forming suffers in its nutrition, and instead of 
going on normally to almost perfect transparency, it 
remains opaque. And the patient will, in consequence, 
carry a white bar across two or three of his nails for 
from three to nine months after the illness, according 
to the rate of growth of his nails. Not infrequently 
this white bar will enable you to ask a patient the ques- 
tion, " Did you not have a serious illness of some sort 
two, three, or six months ago ?" according to the posi- 
tion of the bar. And his fearsome astonishment, if he 
answers your question in the affirmative, is amusing 
to see. You will be lucky if, in future, he does n't in- 
cline to regard you as something uncanny and little 
less than a wizard. 

Another of the score of interesting changes in the 
hand, which, though not very common, is exceedingly 
significant when found, is a curious thickening or club- 
bing of the ends of the fingers, with extreme curvature 
of the nails, which is associated with certain forms of 
consumption. So long has it been recognized that it is 
known as the " Hippocratic finger," on account of the 
vivid description given of it by the Greek Father of 
Medicine, Hippocrates. It has lost, however, some 
of its exclusive significance, as it is found to be asso- 
ciated also with certain diseases of the heart. It seems 
to mean obstructed circulation through the lungs. 


Next after the face and the hand would come the 
carriage and gait. When a man is seriously sick he is 
sick all over. Every muscle in his body has lost its 
tone, and those concerned with the maintenance of the 
erect position, being last developed, suffer first and 
heaviest. The bowed back, the droop of the shoulders, 
the hanging jaw, and the shuffling gait, tell the story 
of chronic, wasting disease more graphically than 
words. We have a ludicrously inverted idea of cause 
and effect in our minds about " a good carriage." We 
imagine that a ramrod-like stiffening of the backbone, 
with the head erect, shoulders thrown back and chest 
protruded, is a cause of health, instead of simply being 
an effect, or one of the incidental symptoms thereof. 
And we often proceed to drill our unfortunate patients 
into this really cramped and irrational attitude, under 
the impression that by making them look better we 
shall cause them actually to become so. The head- 
erect, chest-out, fingers-down-the-seam-of-your trou- 
sers position of the drillmaster is little better than a 
pose intended chiefly for ornament, and has to be 
abandoned the moment that any attempt at movement 
or action is begun. 

So complete is this unconscious muscular relaxa- 
tion, that it is noticeable not only in the standing and 
sitting position, but also when lying down. When a 
patient is exceedingly ill, and in the last state of en- 
feeblement, he cannot even lie straight in bed, but col- 
lapses into a curled -up heap in the middle of the bed, 
the head even dropping from the pillow and falling on 
the chest. Between this debacle and the slight droop 


of shoulders and jaw indicative of beginning trouble 
there are a thousand shades of expression significant 
instantly to the experienced eye. 

Though more limited in their application, yet most 
significant when found, are the alterations of the gait 
itself. Even a maker of proverbs can tell at a glance 
that "the legs of the lame are not equal." From the 
limp, coupled with the direction in which the toe or 
foot is turned, the tilt of the hips, the part of the foot 
that strikes first, the presence or absence of pain-lines 
on the face, a snap diagnosis can often be made as to 
whether the trouble is paralysis, hip- joint disease, knee 
or ankle mischief, of flatfoot, as your patient limps 
across the room. Even where both limbs are affected 
and there is no distinct limp, the form of shuffle is 
often significant. 

Several of the forms of paralysis have each its sig- 
nificant gait. For instance, if a patient comes in with 
a firm, rather precise, calculated sort of gait, " clump- 
ing" each foot upon the floor as if he had struck it an 
inch sooner than he had expected, and clamping it 
there firmly for a moment before he lifts it again, as 
though he were walking on ice, with more knee action 
than seems necessary, you would have a strong sus- 
picion that you had to deal with a case of locomotor 
ataxia, in which loss of sensation in the soles of the feet 
is one of the earliest symptoms. If so, your patient, 
on inquiry, will tell you that he feels as if there were 
a blanket or even a board between his soles and the 
surface on which he steps. If a quick glance at the 
pupils shows both smaller or larger than normal, and 


on turning his face to the light they fail to contract, 
your suspicion is confirmed ; while if, on asking him 
to be seated and cross his legs, a tap on the great ex- 
tensor tendon of the knee-joint just below the patella 
fails to elicit any quick upward jerk of the foot, the 
so-called "knee-kick," then you may be almost sure 
of your diagnosis, and proceed to work it out at your 

On the other hand, if an elderly gentleman enters 
with a curiously blank and rather melancholy expres- 
sion of countenance, holding his cane out stiffly in front 
of him, and comes toward you at a rapid, toddling gait, 
throwing his feet forward in quick, short steps, as if, 
if he failed to do so, he would fall on his face, while 
at the same time a vibrating tremor carries his head 
quickly from side to side, you are justified in suspect- 
ing that you have to do with a case of paralysis agitans, 
or shaking palsy. 

Last of all, your physiognomy of disease includes 
not merely its face, but its voice ; not only the picture 
that it draws, but the sound that it makes. For, when 
all has been allowed and discounted that the most 
hardened cynic or pessimistic agnostic can say about 
speech being given to man to conceal his thoughts, 
and the hopeless unreliability of human testimony, 
two-thirds of what your patients tell you about their 
symptoms will be found to be literally the voice of the 
disease itself speaking through them. They may tell 
you much that is chiefly imaginary, but even imagina- 
tion has got to have some physical basis as a starting- 
point. They may tell you much that is clearly and 


ludicrously irrelevant, or untrue, on account of inac- 
curacy of observation, confusion of cause and effect, 
or a mental color-blindness produced by the disease 
itself. But these things can all be brushed aside like 
the chaff from the wheat if checked up by the picture 
of the disease in plain sight before you. 

In the main, the great mass of what patients tell you 
is of great value and importance, and, with proper de- 
ductions, perfectly reliable. In fact, I think it would 
be safe to say that a sharp observer would be able to 
make a fairly and approximately accurate diagnosis 
in seven cases out of ten, simply by what his eye and his 
touch tell him while listening to symptoms recounted 
by the patient. Time and again have I seen an exam- 
ination made of a reasonably intelligent patient, and 
when the recital had been finished and the hawk-like 
gaze had traveled from head to foot and back again, 
from ear-tip to finger-nail, from eye to chest, a symp- 
tom which the patient had simply forgotten to mention 
would be promptly supplied ; and the gasp with which 
the patient would acknowledge the truth of the sug- 
gestion was worth traveling miles to see. 

Of course, you pay no attention to any statement of 
the patient which flatly contradicts the evidence of your 
own senses. But even where patients, through some 
preconceived notion, or from false ideas of shame or 
discredit attaching to some particular disease, are try- 
ing to mislead you, the very vigor of their efforts will 
often reveal their secret, just as the piteous broken- 
winged flutterings of the mother partridge reveal in- 
stantly to the eye of the bird-lover the presence of the 


young which she is trying to lure him away from. Only 
let a patient talk enough about his or her symptoms, 
and the truth will leak out. 

The attitude of impatient incredulity toward the 
stories of our patients, typified by the story of that 
great surgeon, but greater bear, Dr. John Abernethy, 
has passed, never to return. When a lady of rank came 
into his consulting-room, and, having drawn off her 
wraps and comfortably settled herself in her chair, 
launched out into a luxurious recital of symptoms, in- 
cluding most of her family history and adventures, he, 
after listening about ten minutes pulled out his watch 
and looked at it. The lady naturally stopped, open- 
mouthed. " Madam, how long do you think it will 
take you to complete the recital of your symptoms ? " 
" Oh, well," the lady floundered, embarrassed, 
"I hardly know." "Well, do you think you could fin- 
ish in three-quarters of an hour?" Well, she supposed 
she could, probably. " Very well, madam. I have an 
operation at the hospital in the next street. Pray con- 
tinue with the recital of your symptoms, and I will re- 
turn in three-quarters of an hour and proceed with the 
consideration of your case!" 

When you can spare the time, and no time is 
wasted which is spent in getting a thorough and ex- 
haustive knowledge of a serious case, it is as good 
as a play to let even your hypochondriac patients, and 
those who are suffering chiefly from " nervous prosper- 
ity" in its most acute form, set forth their agonies and 
their afflictions in their fullest and most luxurious 
length, breadth, and thickness, watching meanwhile 


the come and go of the lines about the face-dials, the 
changes of the color, the sparkling and dulling of the 
eye, the droop or pain-cramp, or luxurius loll of each 
group of muscles, and quietly draw your own conclu- 
sions from it all. Many and many a time, in the full 
luxury of self-explanation, they will reveal to you a 
clew which will prove to be the master-key to your con- 
trol of the situation, and their restoration to comfort, 
if not health, which you could n't have got in a week 
of forceps-and-scalpel cross-examination. 

In only one class of patients is this valuable aid to 
knowledge absent, and that is in very young children ; 
and yet, by what may'at first sight seem like a paradox, 
they are, of all others, the easiest in whom to make not 
merely a provisional, but a final, diagnosis. They can- 
not yet talk with their tongues and their lips, but they 
speak a living language in every line, every curve, every 
tint of their tiny, translucent bodies, from their little 
pink toes to the soft spot on the top of their downy 
heads. Not only have they all the muscle-signs about 
the face-dial, of pain or of comfort, but, also, these are 
absolutely uncomplicated by any cross-currents of 
what their elders are pleased to term "thought." 

When a baby knits his brows he is not puzzling over 
his political chances or worrying about his immortal 
soul. He has got a pain somewhere in his little body. 
When his vocal organs emit sounds, whether the gurgle 
or coo of comfort, or the yell of dissatisfaction, they 
are just squeezed out of him by the pressure of his own 
internal sensations, and he is never talking just to hear 
himself talk. Further than this, his color is so exqui- 


sitely responsive to every breath of change in his in- 
terior mechanism, that watching his face is almost like 
observing a reaction in a test-tube, with its precipitate, 
or change of color. In addition, not only will he turn 
pale or flush, and his little muscles contract or relax, 
but so elastic are the tissues of his surface, and so 
abundant the mesh of blood-vessels just underneath, 
that, under the stroke of serious illness, he will literally 
shrivel like a green leaf picked from its stem, or wilt 
like a faded flower. 

A single glance at the tiny face on the cot pillow is 
usually enough to tell you whether or not the little 
morsel is seriously ill. Nothing could be further from 
the truth than the prevailing impression that, because 
babies can't talk, it is impossible, especially for a young 
doctor, to find out what is the matter with them. If 
they can't talk, neither can they tell lies, and when 
they yell "Pin!" they mean pin and nothing else. 

In fact, the popular impression of the puzzled dis- 
comfiture of the doctor before a very small, ailing baby 
is about as rational as the attitude of a good Quaker 
lady in a little Western country town, who had induced 
her husband to subscribe liberally toward the expenses 
of a certain missionary on the West Coast of Africa. 
On his return, the missionary brought her as a mark 
of his gratitude a young half -grown parrot, of one of 
the good talking breeds. The good lady, though de- 
lighted, was considerably puzzled with the gift, and 
explained to a friend of mine that she really did n't 
know what to feed it, and it was n't quite old enough 
to be able to talk and tell her what it wanted ! 



ANCIENT vibrations are hard to stop, and still 
harder to control. Whether they date from our 
driving back by the polar ice-sheet, together with our 
titanic Big Game, the woolly rhinoceros, the mam- 
moth, and the sabre-toothed tiger, from our hunting- 
grounds in Siberia and Norway, or from recollections 
of hunting parties pushing north from our tropical 
birth-lands, and getting trapped and stormbound by 
the advance of the strange giant, Winter, certain it is 
that our subconsciousness is full of ancestral memo- 
ries which send a shiver through our very marrow at 
the mere mention of "cold" or "sleet" or "wintry 

From the earliest dawn of legend cold has always 
been ranked, with hunger and pestilence and storm, 
as one of the demons to be dreaded and fought. 
And, at a little later date, the ancient songs and sayings 
of every people have been full of quaint warnings 
against the danger of a chill, a draft, wet feet, or damp 
sheets. There is, of course, a bitterly substantial basis 
for this feeling, as the dozens of stiffened forms whose 
only winding-sheet was the curling snowdrift, or whose 
coffin the frozen sleet, bear ghastly witness. It was, 
however, long ago discovered that when we were 
properly fed and clothed, the Cold Demon could be 


absolutely defied, even in a tiny hut made out of pressed 
snow and warmed by a smoky seal-blubber lamp; 
that the Storm King could be baffled just by burrow- 
ing into his own snowdrifts and curling up under the 
crust, like an Eskimo dog. Hence, nearly all the 
legends depict the hero as finally conquering the 
Storm King, like Shingebis in the Song of Hiawatha. 
The ancient terror, however, still clings, with a hold 
the more tenacious as it becomes narrowed, to one 
large group of these calamities believed to be produced 
by cold, namely, those diseases supposed to be 
caused by exposure to the weather. Even here, it still 
has a considerable basis in fact ; but the general trend 
of opinion among thoughtful physicians is that this 
basis is much narrower than was at one time supposed, 
and is becoming still more restricted with the progress 
of scientific knowledge. For instance, fifty years ago, 
popular opinion, and even the majority of medical 
belief, was that consumption and all of its attendant 
miseries were chiefly due to exposure to cold. Now we 
know that, on the contrary, abundance of pure, fresh, 
cold air is the best cure for the disease, and foul air 
and overcrowding its chief cause. An almost equally 
complete about-face has been executed in regard to 
pneumonia. Prolonged and excessive exposure to 
cold may be the match that fires the mine, but we are 
absolutely certain that two other things are necessary, 
namely, the presence of the diplococcus, and a lowered 
and somewhat vitiated state of bodily resistance, due 
to age, overwork, underfeeding, or over-indulgence in 


Not only do these two diseases not occur in the land 
of perpetual cold, the frozen North, except where they 
are introduced by civilized visitors, and scarce a 
single death from pneumonia has ever yet occurred 
in the crew of an Arctic expedition, but it has actu- 
ally been proposed to fit up a ship for a summer trip 
through the Arctic regions, as a floating sanatorium 
for consumptives, on account of the purity of the air 
and the brilliancy of the sunlight. 

There is one realm, however, where the swing of this 
ancient superstition vibrates with fullest intensity, and 
that is in those diseases which, as their name implies, 
are still believed to be due to exposure to a lowered 
temperature "common colds." Here again it has 
a certain amount of rational basis, but this is growing 
less and less every day. The present attitude of thought- 
ful physicians may be graphically indicated by the flip- 
pant inquiry of the riddle-maker, " When is a cold not 
a cold?" and the answer, "Two-thirds of the time." 
This much we are certain of already : that the major- 
ity of so-called "colds" have little or nothing to do 
with exposure to a low temperature, that they are en- 
tirely misnamed, and that a better term for them would 
befouls. In fact, this proportion can be clearly and 
definitely proved and traced as infections spreading 
from one victim to another. The best place to catch 
them is not out-of-doors, or even in drafty hallways, 
but in close, stuffy, infected hotel bedrooms, sleeping- 
cars, churches, and theatres. 

Two arguments in rebuttal will at once be brought 
forward, both apparently conclusive. One is that colds 


are vastly more frequent in winter, and the other that 
when you sit in a draft until you feel chilly, you inevi- 
tably have a cold afterward. Both these arguments 
alike, however, are based upon a misunderstanding. 
The frequency of colds in winter is chiefly due to the 
fact that, at this time of the year, we crowd into houses 
and rooms, shutting the doors and windows in order to 
keep warm, and thus provide a ready-made hothouse 
for the cultivation and transmission from one to an- 
other of the influenza and other bacilli. As the brilliant 
young English pulmonary expert, Dr. Leonard Wil- 
liams, puts it, " a constant succession of colds implies 
a mode of life in which all aerial microbes are afforded 
abundant opportunities." At the same time, we take 
less exercise and sit far less in the open air, thus lower- 
ing our general vigor and resisting power and making 
us more susceptible to attack. Those who live out-of- 
doors winter and summer, and who ventilate their 
houses properly, even in cold weather, suffer compara- 
tively little more from colds in the winter-time than 
they do in summer; although, of course, the most vig- 
orous individual, in the best ventilated surroundings, 
will occasionally succumb to some particularly virulent 

The second fact of experience, catching cold after 
sitting in a draft or a chilly room until you begin to 
cough or sneeze, is one to which a majority of us 
would be willing to testify personally, and yet it is 
based upon something little better than an illusion. 
It is a well-known peculiarity of many fevers and in- 
fections to begin with a chill. The patient complains 


of shiverings up and down his spine, his finger-nails 
and his lips become blue, in extreme cases his teeth 
chatter, 'and his limbs begin to twitch and shake, and 
he ends up in a typical ague fit. The best known, be- 
cause most striking, illustration is malaria, or fever 
and ague, "chills and fever," as it is variously termed. 
But this form of attack, milder and much slighter in 
degree, may occur in almost every known infection, 
such as pneumonia, typhoid, tuberculosis, scarlet 
fever, measles, and influenza. It has nothing whatever 
to do with either external or internal temperature ; for 
if you slip a fever-thermometer under your chilling 
patient's tongue, it will usually register anywhere from 
102 to 105. 

This method of attack is especially common, not 
only in influenza, but also in all the other so-called 
"common colds." In fact, when we begin to shiver 
and sneeze and hunt around for an imaginary draft or 
lowering of the temperature which has caused it, we 
are actually in the first stage of the development of an 
infection which was contracted hours, or even days, 

When you begin to shiver and sneeze and run at the 
eyes you are not "catching" cold; you have already 
caught it long before, and it is beginning to break out 
on you. Mere exposure to cold will never cause sneez- 
ing. It takes a definite irritation of the nasal mucous 
membrane, by gas or dust from without, or toxins from 
within, to produce a sneeze. 

As to mere exposure to cold weather and wet and 
storm being able to produce it, it is the almost unani- 


mous testimony of Arctic explorers that, during their 
sojourn of from two to three years in the frozen North, 
they never had so much as a sneeze or a sore throat, 
even though frequently sheltered in extemporized huts, 
and running short of adequate food-supply before 
spring. Within a week of their return to civilization 
they would begin sneezing and coughing, and catch 
furious colds. 

Lumbermen, trappers, hunters, and prospectors in 
Alaska give similar testimony. I have talked with 
scores of these pioneers, visiting them, in fact, in their 
camps under conditions of wet, cold, and exposure 
that would have made one afraid of either pneumonia 
or rheumatism before morning, and found that, so 
long as they remained up in the mountains or out in 
the snow, and no case of influenza, sore throat, or cold 
happened to be brought into the camp, they would 
be entirely free from coughs and colds ; but that, upon 
returning to civilization and sleeping in the stuffy 
room of a rude frontier hotel, they would frequently 
catch cold within three days. 

One unusually intelligent foreman of a lumber camp 
in Oregon told me that an experience of this kind had 
occurred to him three different times that he could 
distinctly recollect. 

It is difficult to catch a cold or pneumonia unless the 
bacilli are there to be caught. Boswell has embalmed 
for us, in the amber of his matchless biography, the 
fact that it had been noted, even in those days, that 
the inhabitants of one of the Faroe Islands never had 
colds in the head except on the rare occasions when 


a ship would touch there usually not oftener than 
once a year. Then, within a week, half the popula- 
tion would be blowing and sneezing. The great Sam- 
uel commented upon the fact at length, and advanced 
the ingenious explanation that, as the harbor was so 
difficult of entry, the ships could beat in only when 
the wind was in a certain quarter, and that quarter 
was the nor'east. Hinc illae lacrima! (Hence these 
weeps !) The colds were caused by the northeast wind 
of unsavory reputation ! How often the wind got into 
the northeast without bringing a ship or colds he ap- 
parently did not speculate. 

To come nearer yet, did you ever catch cold when 
camping out ? I have waked in the morning with the 
snow drifting across the back of my neck, been wet 
to the skin all day, and gone to bed in my wet clothes, 
and slept myself dry; and have lain out all day in a 
November gale, in a hollow scooped in the half-frozen 
ground of the duck-marsh, and felt never a hair the 
worse. Scores of similar experiences will rise up in the 
minds of every camper, hunter, or fisherman. You 
may catch cold during the first day or two out, before 
you have got the foul city air, with its dust and bac- 
teria, out of your lungs and throat, but even this 
rarely happens. 

How seldom one catches cold from swimming, no 
matter how cold the water ; or from boating, or fishing, 
even without the standard prophylactic ; or from 
picnicking, or anything that is done during a day in the 
open air. 

So much for the negative side of the evidence, that 


colds are not often caught where infectious materials 
are absent. Now for the positive side. 

First of all, that typical cold of colds, influenza, or 
the grip, is now unanimously admitted by authorities 
to be a pure infection, due to a definite germ (the ba- 
cillus influenza of Pfeiffer) and one of the most con- 
tagious diseases known. Each of the great epidemics 
of it 1830-33, 1836-37, 1847-48, and, of most vivid 
and unblessed memory, 1889-90 can be traced in its 
stately march completely across the civilized world, be- 
ginning, as do nearly all our world-epidemics, chol- 
era, plague, influenza, etc., in China, and spreading, 
via India or Turkestan, to Russia, Berlin, London, 
New York, Chicago. Moreover, its rate of progress 
is precisely that of the means of travel : camel -train, 
post-chaise, railway, as the case may be. The earlier 
epidemics took two years to spread from Eastern Rus- 
sia to New York; the later ones, forty to sixty days. 
Soon it will beat Jules Verne or George Francis Train. 
So intensely "catching" is it, that letters written by 
sufferers have been known to infect the correspondents 
who received them in a distant town, and become the 
starting-point of a local epidemic. 

Of course, it may be urged that when we have 
proved the grip to be a definite infection, we have taken 
it out of the class of "colds" altogether, and that its 
bacterial origin proves nothing in regard to the rest. 
But a rather interesting state of affairs developed dur- 
ing the search for the true bacillus of influenza: this 
was that a dozen other bacilli and cocci were discov- 
ered, each of which seemed capable of causing all the 


Symptoms of the grip, though in milder form. So that 
the view of the majority of pathologists now is that 
these "influenzoid," or "grip-like" attacks, under 
which come a majority of all common colds, are prob- 
ably due to a number of different milder micro- 

The next fact in favor of the infectious character of 
a cold is that it begins with a chill, followed with a 
fever, runs a definite self -limited course, and, barring 
complications, gets well of itself in a certain time, just 
like the measles, scarlet fever, pneumonia, or any other 
frank infection. 

Colds are also followed by inflammations, or toxic 
attacks in other organs of the body, lungs, stomach, 
bowels, heart, kidneys, nerves, etc., just like diphtheria, 
scarlet fever, or typhoid, only, of course, of milder form 
and less frequently. 

Last, but not least practically convincing, colds may 
be traced from one victim to another, may "run 
through" households, schools, factories, may occur 
after attending church or theatre, may be checked by 
isolating the sufferers; and are now most effectually 
treated by the inhalation of non-poisonous germicidal 
or antiseptic vapors and sprays. 

One of my first experiences with this last method 
occurred in a most unexpected field. An old friend, 
a most interesting and intelligent German, was the 
proprietor of a wild-animal depot, importing foreign 
animals and birds and selling them to the zoological 
gardens and circuses. I used often to drop in there 
to see if he had anything new, and he would come up 


to see me, to tell me his troubles and keep my dissect- 
ing-table supplied with interestingly diseased dead 
beasts and birds. 

One day he came up in a state of great excitement, 
with a very dead and dilapidated parrot in his hand. 

" Choost look, Dogdor ; here 's one of dose measley 
new pollies I god in from Zingapore. De rest iss 
coffin' an' sneezin' to plow dere peaks off, an' all de 
utter caitches iss kitchen him/* 

As parrots are worth from fifteen to thirty dollars 
apiece, "green" (not in color, but training), and he 
had fifty or sixty in the store, the situation was distinctly 
serious. Now, I was no specialist in the peculiar dis- 
eases of parrots, but something had to be done, and, 
with a boldness born of long practice, I drew my bow 
at a venture and let fly this suggestion : 

" Try formalin ; it 's pretty fierce on the eyes and nose, 
but it won't kill 'em; and, if you put a teaspoonful in 
the bottom of each cage, by the time it evaporates no 
germ that gets into that cage will live long enough to 
do any harm." 

Five days later back he came, red-eyed but trium- 
phant. "Dogdor, dot vormaleen iss de pest shtuff I 
effer saw. It mos' shteenk me out of de shtore, an' de 
pollies nearly sneeze dere fedders off, but it shtopt de 
spret, an' it 's cureenall de seek ones, an' I het a cold in 
de het, an' it 's curt me." 

Before using it he had fourteen cases and three 
deaths ; after, only three new cases and no more deaths. 
I would, however, hardly advise any human "coldic" 
to try such heroic treatment offhand, for the pungency 


and painfulness of formalin vapor is something fero- 
cious, though the French physicians, with character- 
istic courage, are making extensive use of it for this 
purpose, with excellent results under careful super- 

Another curious straw pointing in the direction of the 
infectious nature of colds is the "annual cold," or 
"yearly sore throat," from which many of us suffer. 
When we have had it we usually feel fairly safe from 
colds for some months at least, often for a year. The 
only explanation that seems in the least to explain is 
that colds, like other infections, confer an immunity 
against another attack; only, unlike scarlet fever, 
measles, smallpox, etc., this immunity, instead of for 
life, is only for six months or a year. This immunity 
is due to the formation in the blood of protective sub- 
stances known as anti-bodies, which destroy or render 
harmless the invading germs. Flabby, under-venti- 
lated individuals, who are always " catching cold," have 
such weak resisting powers that they form hardly 
enough anti-bodies to terminate the first attack, without 
having enough left to protect them from another for 
more than a few weeks or months. Dr. Leonard 
Williams describes chronic cold-catchers as "people 
who wear flannel next their skins, . . . who know 
they are in a draft because it makes them sneeze ; who, 
in short, live thoroughly unwholesome, coddling lives." 
Strong and vigorous individuals may form enough to 
last them a year, or even two years. 

Now comes the question, "What are we going to do 
about it?" Obviously, we cannot "go gunning" for 


these countless billions of germs, of fifteen or twenty 
different species. Nor can we quarantine every one who 
has a cold. Fortunately, no such radical methods are 
necessary. All we have to do is to take nature's hint of 
the anti-bodies and improve upon it. Healthy cells can 
grow fat on a diet of such germs, and, if we keep our- 
selves vigorous, clean, and well ventilated, we can prac- 
tically defy the " cold " devil and all his works. 

Here is the leitmotif oi the whole fascinating drama 
of infection and immunity. We can study only one 
phrasing here. We shall, of course, catch cold occasion- 
ally, but will throw it off quickly, and probably form 
anti-bodies enough to last us a year or more. How can 
this be done ? First and foremost, by living and 
sleeping as much as possible in the open air. This 
helps in several different ways. First, by increasing 
the vigor and resisting power of our bodies; second, 
by helping to burn up, clean, and rid our tissues of 
waste products which are poisons if retained ; third, 
by greatly reducing the risks of infection. 

You can't catch cold by sitting in a field exposed to 
the draft from an open gate ; though I understand that 
casuists of the old school of the "chill-and-damp" 
theory of colds are still discussing the case of the patient 
who "caught his death o' cold" by having his gruel 
served in a damp basin. 

The first thing to do is to get the outdoor habit. This 
takes time to acquire, but, once formed, you would n't 
exchange it for anything else on earth. The next thing 
is to learn to sit or sleep in a gentle current of air all the 
time you are indoors. You ought to feel uncomfortable 


unless you can feel air blowing across your face night 
and day. Then you are reasonably sure it is fresh, and 
it is the only way to be sure of it. 

But drafts are so dangerous ! As the old rhyme runs, 

But when a draft blows through a hole, 
Make your will and mend your soul. 

Pure superstition ! It just shows what 's in a name. 
Call it a gentle breeze, or a current of fresh air, and no 
one is afraid of it. Call it a "draft," and up go hands 
and eyebrows in horror at once. One of our highest 
authorities on diseases of the lungs, Dr. Norman Bridge, 
has well dubbed it "The Draft Fetich." It is a fetich, 
and as murderous its Moloch. The draft is a friend 
instead of an enemy. What converted most of us to a 
belief in the beneficence of drafts was the open-air 
treatment of consumption ! Hardly could there have 
been a more spectacular proof, a more dramatic defi- 
ance of the bogey. To make a poor, wasted, shivering 
consumptive, in a hectic one hour and a drenching 
sweat the next, lie out exposed to the November 
weather all day and sleep in a ten-knot gale at night ! 
It looked little short of murder ! So much so to some 
of us, that we decided to test it on ourselves before 
risking our patients. 

I can still vividly recall the astonishment with which 
I woke one frosty December morning, after sleeping 
all night in a breeze across my head that literally made 

Each particular hair to stand on end, 
Like quills upon the fretful porcupine, 

not only without the sign of a sniffle, but feeling as if 
I 'd been made new while I slept. 


Then we tried it in fear and trembling on our pa- 
tients, and the delight of seeing the magic it worked ! 
That is an old story now, but it has never lost its charm. 
To see the cough which has defied "dopes "and syrups 
and cough mixtures, domestic, patent, and professional, 
for months, subside and disappear in from three to ten 
days ; the night sweats dry up within a week ; the appe- 
tite come back ; the fever fall ; the strength and color 
return, as from the magic kiss of the free air of the 
woods, the prairies, the seacoast. There 's nothing else 
quite like it on the green earth. Do you wonder that 
we become "fresh-air fiends"? 

The only thing we dread in these camps is the im- 
ported "cold." Dr. Lawrence Flick was the first to 
show us the way in this respect as in several others. He 
put up a big sign at the entrance of White Haven Sana- 
torium, "No persons suffering from colds allowed to 
enter," and traced the only epidemic of colds in the 
sanatorium to the visit of a butcher with the grip. I 
put up a similar sign at the gate of my Oregon camp, 
and never had a patient catch cold from tenting out in 
the snow and "Oregon mists" until the small son of 
the cook came back from the village school, shivering 
and sneezing, when seven of the thirteen patients 
"caught it" within a week. 

What will cure a consumptive will surely not kill a 
healthy man. I am delighted to say that it shows signs 
of becoming a fad now, and sleeping porches are being 
put on houses all over the country. No house in Cali- 
fornia is considered complete without them. The 
ideal bedroom is a small dressing-room, opening on 


a wide screened porch, or balcony, with a door wide 
enough to allow the bed to be rolled inside during 
storms or in severest weather. 

Sleep on a porch, or in a room with windows on two 
sides wide open, and the average living-room or office 
begins to feel stuffy and "smothery" at once. Apply 
the same treatment here. Learn to sit in a gentle draft, 
and you '11 avoid two-thirds of your colds and three- 
fourths of your headaches. It may be necessary in win- 
ter to warm the draft, but don't let any patent method 
of ventilation delude you into keeping your windows 
shut any hour of the day or night. 

On the other hand, 'don't fall into the widespread 
delusion that because air is cold it is necessarily pure. 
Some of the vilest air imaginable is that shut up in those 
sepulchres known as "best bedrooms," which chill 
your very marrow. The rheumatism or snuffles you 
get from sleeping between their icy sheets comes from 
the crop of bacilli which has lurked there since they 
were last aired. The "no heat in a bedroom" dogma 
is little better than superstition, born of those fecund 
parents which mate so often, stinginess and puritanism. 
Practically, the room which will never have a window 
opened in it in winter is the one without any heat. 

Similarly, the air in an underheated church, hall, or 
theatre is almost sure to be foul. The janitor will keep 
every opening closed in order to get the temperature up. 
Some churches are never once decently ventilated from 
December to May. The same old air, with an ever 
richer crop of germs, is reheated and served up again 
every Sunday. The "odor of sanctity" is the residue 


of the breaths and perspiration of successive genera- 
tions. Cleanliness may be next to godliness, but it is 
sometimes an astonishingly long step behind it. 

The next important step is to keep clean, both ex- 
ternally and internally : externally, by cold bathing, 
internally, by exercise. The only reason why a draft 
ever hurts us is because we are full of self-poisons, or 
germs. The self -poisons can be best got rid of by abun- 
dant exercise in the open air and plenty of pure, cold 
H 2 O, internally and externally. 

Food has very little to do with these autotoxins, and 
they are as likely to form on one diet as another. In 
fact, they form normally and in states of perfect health, 
and are poisonous only if retained too long. It is 
simply a question of burning them up, and getting rid 
of them quickly enough, by exercise, with its attend- 
ant deep breathing and perspiration. The lungs are 
great garbage-burners. Exercise every day till you puff 
and sweat. 

A blast of cold air suddenly stops the escape of these 
poisons through the skin and throws them on the lungs, 
liver, or kidneys. The resulting disturbance is the sec- 
ond commonest form of a "cold," and covers perhaps 
a third of all cases occurring. This is the cold that can 
be prevented by the cold bath. Keep the skin hardened 
and toned up to such a pitch that no reasonable chill 
will stop it from excreting, and you are safe. Never 
depend on clothing. The more you pile on, the more 
you choke and "flabbify" the skin and make it ready 
to "strike" on the first breath of cold air. Too heavy 
flannels are cold-breeders, and chest-protectors inven- 


tions of the evil one. Trust the skin ; it is one of the 
most important and toughest organs in the body, if 
only given half a chance. 

But the most frequent way in which drafts precipi- 
tate a cold is by temporarily lowering the vital resist- 
ance. This gives the swarms of germs present almost 
constantly in our noses, throats, stomachs, bowels, etc., 
the chance they have been looking for to break 
through the cell barrier and run riot in the body. 

So long as the pavement-cells of our mucous mem- 
branes are healthy, they can keep them out indefinitely. 
Lower their tone by cold, fatigue, underfeeding, and 
their line is pierced in a dozen places at once. One of the 
many horrifying things which bacteriology has revealed 
is that our bodies are simply alive with germs, even in 
perfect health. One enthusiastic dentist has discovered 
and described no less than thirty-three distinct species, 
each one numbering its billions, which inhabit our 
gums and teeth. Our noses, our stomachs, our intes- 
tines, each boasts a similar population. Most of them 
do no harm at all; indeed, some probably assist in the 
processes of digestion ; others are camp-followers, living 
on our leavings; others, captive enemies which have 
been clubbed into peaceful behavior by our leucocyte 
and anti-body police. 

For instance, not a few healthy noses and throats 
contain the bacillus of diphtheria and the diplococcus 
of pneumonia. We are beginning to find that these last 
two groups will bear watching. Like camp-followers 
elsewhere, they carry knives, and are not above using 
them on the wounded after dark. In fact, they have a 


cheerful habit of taking a hand in any disturbance that 
starts in their bailiwick, and usually on the side against 
the body-cells. 

Finally, while clearly realizing that the best defense 
is attack, and that our chief reliance should be upon 
keeping ourselves in such fighting trim that we can 
"eat 'em alive" at any time, there is no sense in run- 
ning easily avoidable risks, and we should keep away 
from infection as far as possible. If a child comes to 
school heavy-eyed, hoarse, and snuffling, the teacher 
should send him home at once. He will only waste 
his time attempting to study in that trim, and may infect 
a score of others. Moreover, it may be remarked, 
parenthetically, that these are also symptoms of the be- 
ginning of measles, scarlet fever, and diphtheria, and 
two-thirds of all cases of these would be sent home be- 
fore they could infect any one else if this procedure 
were the rule. 

If your own child develops a cold, if mild, keep him 
playing out-of-doors by himself ; or if severe, keep him 
in bed, in a well-ventilated room, for three or four days. 
He '11 get better twice as quick as if at school, and the 
rest of the household will escape. 

When you wake with a stuffed head and aching 
bones, stay at home for a few days if possible, out of 
regard for your customers, your fellow-clerks, or your 
office force, as well as yourself. If one of your employ- 
ees comes to work shivering, give him three days' vaca- 
tion on full pay. If it runs through the force, you'll 
lose five times as much in enforced sick-leaves, slow- 
ness, and mistakes. Above all, don't go to any public 


gatherings, to church, the theatre, or parties, when 
you are snuffling and coughing. You are not exactly a 
joy to your beholders, even if you don't infect them. 
It is advisable, and well worth the trifling trouble and 
expense, to fumigate thoroughly with formalin all 
churches, theatres, and schoolrooms at least once a 
month. Reasonable and public-spirited precautions 
of this sort are advisable, not only to avoid colds them- 
selves, which are disagreeable and dangerous enough, 
but because mild infections of this sort are far the com- 
monest single means of making a breach in our body- 
ramparts through which more serious diseases like con- 
sumption, pneumonia' and rheumatism may force an 

Colds do not " run into " consumption or pneumonia, 
but they bear much the same relation to them that good 
intentions are said to do to the infernal regions. They 
release the lid of a perfect Pandora's box of distempers 
tuberculosis, pneumonia, rheumatism, bronchitis, 
Bright's disease, neuritis, endocarditis. A cold is no 
longer a joke. A generation ago a prominent physician 
was asked by an anxious mother, " Doctor, how would 
you treat a cold ?" 

"With contempt, madam," replied the great man. 

That day is past, and has lasted too long. Intelli- 
gently regarded and handled, they are the least harm- 
ful of diseases; neglected, one of the most dangerous, 
because there are such legions of them. To sum up, 
if you wish to revel in colds, all that is necessary is to 
observe the following few and simple rules : 

Keep your windows shut. 


Avoid drafts as if they were a pestilence. 

Take no exercise between meals. 

Bathe seldom, and in warm water. 

Wear heavy flannels, chest-protectors, abdominal 
bandages, and electric insoles. 

Have no heat in your bedroom. 

Never let anything keep you away from church, the 
theatre, or parties, in winter. 

Never go out-of-doors when it 's windy, or rainy, or 
wet underfoot, or cold, or hot, or looks as if it was going 
to be any of these. 

Be just as intimate and affectionate as possible with 
every one you know who has a cold. Don't neglect them 
on any account. 



IN all ages it has been accounted a virtue to keep 
your mouth shut chiefly, of course, upon moral 
or prudential grounds, for fear of what might issue from 
it if opened. Then came physiology to back up the 
maxim, on the ground that the open mouth was also 
dangerous on account ofwhat might be inhaled into it. 
Oddly enough, in this instance, both morality and 
science have been beside the mark to the degree that 
they have been mistaking a symptom for a cause. This 
has led us to absurd and injurious extremes in both 
cases. On the moral and prudential side it has led 
to such outrageous exaggerations as the well-known 
and oft-quoted proverb, " Speech is silver, but silence 
is golden." Articulate speech, the chiefest triumph and 
highest single accomplishment of the human species, 
the handmaid of thought and the instrument of pro- 
gress, is actually rated below silence, the attribute of the 
clod and of the dumb brute, the easy refuge of cow- 
ardice and of stupidity. 

Easily eight-tenths of all speech is informing, educa- 
tive, helpful in some modest degree; while fully that 
proportion of silence is due to lack of ideas, cowardice, 
or designs that can flourish only in darkness. It is 
not the abundance of words, but the scarcity of ideas, 


that makes us flee from " the plugless word-spout" and 
avoid the chatterbox. 

Similarly, upon the physical side, because children 
who breathe through the mouth are apt to have a vacant 
expression, to be stupid and inattentive, undersized, 
pigeon-breasted, with short upper lip and crowded 
teeth, we have leaped to the conclusion that it is a 
fearsome and dangerous thing to breathe through your 
mouth. All sorts of stories are told about the danger- 
ousness of breathing frosty air directly into the lungs. 
Invalids shut themselves scrupulously indoors for 
weeks and even months at a stretch, for fear of the 
terrible results of a "blast of raw air" striking into 
their bronchial tubes. All sorts of absurd instruments 
of torture, in the form of "respirators" to tie over the 
mouth and nose and "keep out the fog," are invented, 
and those who have the slightest tendency to bronchial 
or lung disturbances are warned upon pain of their life 
to wrap up their mouths whenever they go out-of-doors. 

Asa matter of fact, there is exceedingly little evi- 
dence to show that pure, fresh, open air at any reason- 
able temperature and humidity ever did harm when in- 
haled directly into the lungs. In fact, a considerable 
proportion of us, when swinging along at a lively gait on 
the country roads, or playing tennis or football, or en- 
gaged in any form of active sport, will be found to keep 
our lips parted and to inhale from a sixth to a third of 
our breath in this way, and with no injurious results 
whatever. Nine-tenths of all the maladies believed to 
be due to breathing even the coldest and rawest of air 
are now known to be due to invading germs. 


Nevertheless, mouth-breathing in all ages has been 
regarded as a bad habit, and with good reason. It was 
only about thirty years ago that we began to find out 
why. A Danish throat surgeon, William Meyer, whose 
death occurred only a few months ago, discovered, 
in studying a number of children who were affected 
with mouth-breathing, that in all of them were present 
in the roof of the throat curious spongy growths, which 
blocked up the posterior opening of the nostrils. As 
this mass was made up of a number of smaller lobules, 
and the tissue appeared to be like that of a lymphatic 
gland, or "kernel," the name "adenoids" (gland-like) 
was given to them. Later they were termed post-nasal 
growths, from the fact that they lay just behind the rear 
opening of the nostrils ; and these two names are used 
interchangeably. Our knowledge has spread and 
broadened from this starting-point, until we now know 
that adenoids are the chief, yes, almost the sole primary 
cause, not merely of mouth-breathing, but of at least 
two-thirds of the injurious effects which have been at- 
tributed to this habit. 

Mouth-breathing is not simply a bad habit, a careless 
trick on the part of the child. We have come to realize 
that physical bad habits, as well as many mental and 
moral ones, have a definite physical cause, and that no 
child ever becomes a mouth-breather as long as he can 
breathe comfortably through his nose. 

This clears the ground at once of a considerable 
amount of useless lumber in the shape of advice to 
train the child to keep his mouth shut. I have even 
known mothers who were in the habit of going around 


after their helpless offspring were asleep and gently 
but firmly pushing up the little jaw "and pressing the 
lips together until some sort of an attempt at respi- 
ration was made through the nostrils. Advertisements 
still appear of sling-like apparatuses for holding the 
jaws closed during sleep. 

To attempt to stop mouth-breathing before provid- 
ing abundant air-space through the nostrils is not only 
irrational, but cruel. Of course, after the child has 
once become a mouth-breather, even after the nostrils 
have been made perfectly free, it will not at once aban- 
don its habit of months or years, and disciplinary 
measures of some sort may then be needed for a time. 
But the hundred-times-repeated admonition, "For 
heaven's sake, child, shut your mouth ! Don't go around 
with it hanging open like that!" unless preceded by 
proper treatment of the nostrils, will have just about 
as much effect upon the habit as the proverbial water 
on a duck's back. No use trying to close his mouth by 
any amount of opening of your own. 

Fortunately, as does not always happen, with our 
discovery of the cause has come the knowledge of the 
cure ; and we are able to say with confidence that, wide- 
spread and serious as are disturbances of health and 
growth associated with mouth-breathing, they can be 
absolutely prevented and abolished. 

What, then, is the cause of this nasal obstruction, and 
when does it begin to operate ? The primary cause is 
catarrhal inflammation, with swelling and thickening of 
the secretions, and it may begin to operate anywhere 
from the seventh month to the seventh year. A neg- 


lected attack, or series of attacks, of " snuffles," colds 
in the head, catarrhs, in infants and young children, 
will set up a slow inflammation of this glandular mass 
at the back of the nostrils a tonsil, by the way 
and start its enlargement. 

Whether we know anything about adenoids them- 
selves or not, we are all familiar with their handiwork. 
The open mouth, giving a vacant expression to the 
countenance, the short upper lip, the pinched and 
contracted nostrils, the prominent and irregular teeth, 
the listless expression of the eyes, the slow response to 
request or demand, we have seen a score of times in 
every school room. Coupled with these facial features 
are apt to be found on closer investigation a lack of 
interest in both work and play, an impaired appetite, 
restless sleep, and a curious general backwardness of 
development, both bodily and mental, so that the child 
may be from one to four inches below the normal 
height for his years, from five to fifteen pounds under 
weight, and from one to three grades behind his proper 
school position. Very often, also, his chest is inclined 
to be narrow, the tip of his breastbone to be sunken, 
and his abdomen larger in girth than his chest. Is it 
possible that the mere inhaling of air directly into the 
lungs, even though it be imperfectly warmed, moist- 
ened, and filtered, as compared with what it would be 
if drawn through the elaborate "steam-coils" in the 
nostrils for this purpose, can have produced this array 
of defects ? It is incredible on the face of it and un- 
founded in fact. Fully two-thirds of these can be 
traced to the direct influence of the adenoids. 


These adenoids, it may briefly be stated, are the re- 
sult of an enlargement of a tonsil, or group of small ton- 
sils, identical in structure with the well-known bodies 
of the same name which can be seen on either side 
of the throat. They have the same unfortunate faculty 
as the other tonsils for getting into hot water, flaring up, 
inflaming, and swelling on the slightest irritation. And, 
unfortunately, they are so situated that their capacity 
for harm is far greater than that of the other tonsils. 
They seem painfully like the chip on the shoulder of 
a fighting man, ready to be knocked off at the lightest 
touch and plunge the whole body into a scrimmage. 
Their position is a little difficult to describe to one not 
familiar with the anatomy of the throat, especially as 
they cannot be seen except with a laryngeal mirror; 
but it may be roughly stated as in the middle of the 
roof of the throat, just at the back of the nostrils, 
and above the soft palate. From this coign of vantage 
they are in position to produce serious disturbances 
of two of our most important functions, respiration 
and digestion, and three out of the five senses, 
smell, taste, and hearing. 

We will begin with their most frequent and most se- 
rious injurious effect, though not the earliest, the 
impairment of the child's power of attention and intel- 
ligence. So well known is their effect in this respect 
that there is scarcely an intelligent and progressive 
teacher nowadays who is not thoroughly posted on 
adenoids. Some of them will make a snap diagnosis as 
promptly and almost as accurately as a physician ; and 
when once they suspect their presence, they will leave 


no stone unturned to secure an examination of the child 
by a competent physician, and the removal of the 
growths, if present. They consider it a waste of time 
to endeavor to teach a child weighted with this handi- 
cap. How keenly awake they are to their importance 
is typified by the remark of a prominent educator five 
or six years ago : 

"When I hear a teacher say that a child is stupid, 
my first instinctive conclusion is either that the child 
has adenoids, or that the teacher is incompetent." 

The lion's share of their influence upon the child's 
intelligence is brought about in a somewhat unexpected 
and even surprising manner, and that is by the effects 
of the growths upon his hearing. You will recall that 
this third tonsil was situated at the highest point in the 
roof of the pharynx, or back of the throat. The first 
effect of its enlargement is naturally to block the pos- 
terior opening of the nostrils. But it has another most 
serious vantage-ground for harm in its peculiar position. 
Only about three-fourths of an inch below it upon either 
side open the mouths of the Eustachian tubes, the little 
funnels which carry air from the throat out into the 
drum-cavity of the ear. You have frequently had prac- 
tical demonstrations of their existence, by the well- 
known sensation, when blowing your nose vigorously, 
of feeling something go "pop" in the ear. This sensa- 
tion was simply due to a bubble of air being driven 
out through this tube from the back of the throat, 
under pressure brought to bear in blowing the nose. 
The luckless position of the third tonsil could hardly 
have been better planned if it had been devised for the 


special purpose of setting up trouble in the mouths of 
these Eustachian tubes. 

Just as soon as the enlargements become chronic, 
they pour out a thick mucous secretion, which quickly 
becomes purulent, or, in the vernacular, "matter." 
This trickles down on both sides of the throat, and 
drains right into the open mouth of the Eustachian 
tube. Not only so, but these Eustachian tubes are the 
remains of the first gill-slits of embryonic life, and, like 
all other gill-slits, have a little mass of this same lym- 
phoid or tonsilar tissue surrounding them. This also 
becomes infected and inflamed, clogs the opening, and 
one fatal day the inflammation shoots out along the tube, 
and the child develops an attack of earache. At least 
two-thirds of all cases of earache, and, indeed, five- 
sixths of all cases of deafness in children, are due to 

Earache is simply the pain due to acute inflammation 
in the small drum-cavity of the ear. This in the large 
majority of cases will subside and drain back again 
into the throat through the Eustachian tube. In a fair 
percentage of instances, however, it will break in the 
opposite direction, and we have the familiar ruptured 
drum and discharge from the ear. In either case the 
drum becomes thickened, so that it can no longer 
vibrate properly ; the delicate little chain of bones be- 
hind it, like the levers of a piano, becomes clogged, 
and the child becomes deaf, whether a chronic dis- 
charge be present or not. 

This is the secret of his "inattention," his "indiffer- 
ence," even of his apparent disobedience and re- 


belliousness. What other children hear without an 
effort he has to strain every nerve to catch. He mis- 
understands the question that is asked of him, makes an 
absurd answer, and is either scolded or laughed at. It 
is n't long before he falls into the attitude : " Well, I 
can't get it right, anyhow, no matter how I try, so I 
don't care." Up to five or ten years ago the puzzled 
and distracted teacher would simply report the child 
for stupidity, indifference, and even insubordination. 
In nine cases out of ten, when children are naughty or 
stupid, they are really sick. 

Not content with dulling one of the child's senses, 
these thugs of the body-politic proceed to throttle two 
others smell and taste. Obviously the only way of 
smelling anything is to sniff its odor into your nose. 
And if this be more or less, or completely, blocked up, 
and its delicate mucous membranes coated with a 
thick, ropy discharge, you will not be able to distin- 
guish anything but the crudest and rankest of odors. 
But what has this to do with taste ? Merely that two- 
thirds of what we term "taste" is really smell. Seal 
the nostrils and you can't " tell chalk from cheese," not 
even a cube of apple from a cube of onion, as scores of 
experiments have shown. We all know how flat tea, 
coffee, and even our own favorite dishes taste when we 
have a bad cold, and this, remember, is the permanent 
condition of the palate of the poor little mouth-breather. 
No wonder his appetite is apt to be poor, and that even 
what food he eats will not produce a flow of " appetite 
juice" in the stomach, which Pavloff has shown to be 
so necessary to digestion. No wonder his digestion is 


apt to go wrong, ably assisted by the continual drip of 
the chronic discharge down the back of his throat ; his 
bowels to become clogged and his abdomen distended. 

But the resources for mischief of this pharyngeal 
"Old Man of the Sea" are not even yet exhausted. 
Next comes a very curious and unexpected one. We 
have all heard much of "the struggle for existence" 
among plants and animals, and have had painful 
demonstrations of its reality in our own personal expe- 
rience. But we hardly suspected that it was going on in 
our own interior. Such, however, is the case ; and when 
once one organ or structure falls behind the others 
in the race of growth, its neighbors promptly begin 
to enrcoach upon and take advantage of it. Emer- 
son was right when he said, " I am the Cosmos," the 

Now, the mouth and the nose were originally one 
cavity. As Huxley long ago remarked, "When Nature 
undertook to build the skull of a land animal she was 
too lazy to start on new lines, and simply took the old 
fish-skull and made it over, for air-breathing purposes." 
And a clumsy job she made of it ! 

It may be remarked, in passing, that mouth-breath- 
ing, as a matter of history, is an exceedingly old and 
respectable habit, a reversion, in fact, to the method 
of breathing of the fish and the frog. " To drink like 
a fish" is a shameful and utterly unfounded aspersion 
upon a blameless creature of most correct habits and 
model deportment. What the poor goldfish in the bowl 
is really doing with his continual "gulp, gulp!" is 
breathing not drinking. 


This remodeling starts at a very early period of our 
individual existence. A horizontal ridge begins to grow 
out on either side of our mouth-nose cavity, just above 
the roots of the teeth. This thickens and widens into 
a pair of shelves, which finally, about the third month 
of embryonic life, meet in the middle line to form the 
hard palate or roof of the mouth, which forms also the 
floor of the nose. Failure of the two shelves to meet 
properly causes the well-known "cleft-palate, "and, if 
this failure extends forward to the jaw, "hare-lip." In 
the growth of a healthy child a balance is preserved 
between these lower and upper compartments of the 
original mouth-nose cavity, and the nose above growing 
as rapidly in depth and in breadth as the mouth be- 
low, the horizontal partition between the floor of 
the nose and the roof of the mouth is kept compara- 
tively flat and level. In adenoids, however, the nostrils 
no longer being adequately used, and consequently 
failing to grow, and the mouth cavity below growing 
at the full normal rate, it is not long before the mouth 
begins to encroach upon the nostrils by pushing up the 
partition of the palate. As soon as this upward bulge 
of the roof of the mouth occurs, then there is a diminu- 
tion of the resistance offered by the horizontal healthy 
palate to the continual pressure of the muscles of the 
cheeks and of mastication upon the sides of the upper 
jaw, the more readily as the tongue has dropped 
down from its proper resting position up in the roof of 
the mouth. These are pushed inward, the arch of the 
jaw and of the teeth is narrowed, the front teeth are 
made to project, and, instead of erupting, with plenty 


of room, in even, regular lines, are crowded against and 
overlap one another. 

When from any cause the lower jaw habitually hangs 
down, as in the open mouth, it tends to be thrown 
slightly forward in its socket. Then, when the jaws 
close again, the arches of the upper and lower teeth 
no longer meet evenly. Instead of "locking" at almost 
every point, as they should, they overlap, or fall behind, 
or inside, or outside, of each other. So that instead of 
every tooth meeting its fellow of the jaw above evenly 
and firmly, they strike at an angle, slip past or even 
miss one another, and thus increase the already ex- 
isting irregularity and overlapping. Each individual 
tooth, missing its best stimulus to healthy growth and 
vigor, firm and regular pressure and exercise against 
its fellow in the jaw above or below, gets a twist in its 
socket, wears away irregularly, and becomes an easy 
prey to decay, while from failure of the entire upper and 
lower arches of the teeth to meet squarely and press 
evenly and firmly against one another, the jaws fail to 
expand properly and the tendency to narrowing of the 
tooth-arches and upward vaulting of the palate is in- 

In short, we are coming to the conclusion that from 
half to two-thirds of all cases of "crowded mouth," 
irregular teeth, and high-arched palate in children are 
due to adenoids. Progressive dentists now are insisting 
upon their little patients, who come to them with these 
conditions, being examined for adenoids, and upon 
the removal of these, if found, as a preliminary measure 
to mechanical corrective treatment. Cases are now on 


record of children with two, three, or even four genera- 
tions of crowded teeth and narrow mouths behind 
them, but who, simply by being sharply watched for 
nasal obstruction and the symptoms of adenoids, by the 
removal of these latter as soon as they have put in an 
appearance, have grown up with even, regular, well- 
developed teeth and wide, healthy mouths and jaws. 
Unfortunately, attention to the adenoids will not re- 
move these defects of the jaws and teeth after they have 
been produced. But, if the child be under ten, or even 
twelve, years of age, their removal may yet do much 
permanently to improve the condition, and is cer- 
tainly well worth while on general principles. 

Take care of the nose, and the jaws will take care of 
themselves. An ounce of .adenoids-removal in the 
young child is worth a pound of orthodontia teeth- 
straightening in the boy or girl ; though both are 
often necessary. 

The dull, dead tone of the voice in these children is, 
of course, an obvious effect of the blocked nostrils. 
Similarly, the broken sleep, with dreams of suffocation 
and of " Things Sitting on the Chest," are readily ex- 
plained by the desperate efforts that the little one makes 
to breathe through clogging nostrils, in which the dis- 
charges, blown and sneezed out in the daytime, dry and 
accumulate during sleep, until, half-suffocated, it "lets 
go" and draws in huge gulps of air through the open 
mouth. No child ever became a mouth-breather from 
choice, or until after a prolonged struggle to continue 
breathing through its nose. 

This brings us to the question, What are these ade- 


noids, and how do they come to produce such serious 
disturbances ? This can be partially answered by say- 
ing that they are tonsils and with all a tonsil's suscep- 
tibility to irritation and inflammation. But that only 
raises the further question, What is a tonsil ? And to 
that no answer can be given but Echo's. They are one 
of the conundrums of physiology. All we know of them 
is that they are not true glands, as they have neither 
duct nor secretion, but masses of simple embryonic 
tissue called lymphoid, which has a habit of grouping 
itself about the openings of disused canals. This is 
what accounts for their position in the throat, as they 
have no known useful function. The two largest, or 
throat-tonsils, surround the inner openings of the sec- 
ond gill-slits of the embryo ; the lingual tonsil, at the 
base of the tongue below, encircles the mouth of the 
duct of the thyroid gland (the goitre gland) ; and our 
own particular Pandora's Box above, in the roof of the 
pharynx, is grouped about the opening of another dis- 
used canal, which performs the singular and appar- 
ently most uncalled-for office of connecting the cavity 
of the brain with the throat. They can all of them be 
removed completely without any injury to the general 
health, and they all tend to shrink and become smaller 
in the case of the topmost, or pharyngeal, almost 
disappear after the twelfth or fourteenth year. 

Not only have they an abundant crop of troubles of 
their own, as most of us can testify from painful ex- 
perience, but they serve as a port of entry for the germs 
of many serious diseases, such as tuberculosis, rheuma- 
tism, diphtheria, and possibly scarlet fever. They ap- 


pear to be a strange sort of survival or remnant, not 
even suitable for the bargain-counter, a hereditary 
leisure class in the modern democracy of the body, a 
fertile soil for all sorts of trouble. 

Here, then, we have this little bunch of idle tissue, 
about the size of a small hazelnut, ready for any mis- 
chief which our Satan-bacilli may find for its hands to 
do. A child kept in a badly ventilated room inhales into 
his nostrils irritating dust or gases, or, more commonly 
yet, the floating germs of some one or more of those 
dozen mild infections which we term " a common cold." 
Instantly irritation and swelling are set up in the ex- 
quisitely elastic tissues of the nostrils, thick, sticky 
mucous, instead of the normal watery secretion, is 
poured out, the child begins to sneeze and snuffle and 
"run at the nose," and either the bacteria are carried 
directly to this danger sponge, right at the back of the 
nostrils, or the inflammation gradually spreads to it. 
The mucous membrane and tissues of the nose have an 
abundance of vitality, like most hard workers, 
and usually react, overwhelm, and destroy the invading 
germs, and recover from the attack; but the useless 
and half-dead tissue of the pharyngeal tonsil has much 
less power of recuperation, and it smoulders and in- 
flames, though ultimately, perhaps, it may swing round 
to recovery. Often, however, a new cold will be caught 
before this has fully occurred, and then another one a 
month or so later, until finally we get a chronically 
thickened, inflamed, and enlarged condition of this in- 
teresting, but troublesome, body. What its capabili- 
ties are in this respect may be gathered from the fact 


that, while normally of the size of a small hazelnut, it is 
no uncommon thing to find a mass which absolutely 
blocks up the whole of the upper part of the pharynx, 
and may vary from the size of a robin's egg to that of a 
large English walnut, or even a small hen's egg, accord- 
ing to the age of the child and the size of the throat. 

Dirt has been defined as "matter out of place," 
and the pharyngeal tonsil is an excellent illustration. 
Nature is said never to make mistakes, but she is apt to 
be absent-minded at times, and we are tracing now not 
a few of the troubles that our flesh is heir to, to little 
oversights of hers scraps of inflammable material 
left lying about among the cogs of the body-machine, 
such as the appendix, the gall-bladder, the wisdom 
teeth, and the tonsils, One day a spark drops on them, 
or they get too near a bearing or a "hot-box," and, in 
a flash, the whole machine is in a blaze. 

Never neglect snuffles or "cold in the head" in a 
young child, and particularly in a baby. Have it treated 
at once antiseptically, by competent hands, and learn 
exactly what to do for it on the appearance of the earli- 
est symptoms in the future, and you will not only save 
the little ones a great deal of temporary discomfort and 
distress, for it is perfect torment to a child to breathe 
through its mouth at first, but you will ward off 
many of the most serious troubles of infancy and child- 
hood. We can hardly expect to prevent all development 
of adenoids by these prompt and painless stitches in 
time, for some children seem to be born peculiarly 
subject to them, either from the inheritance of a par- 
ticular shape of nose and throat, "the family nose," 


as it has been called, or from some peculiar spongi- 
ness and liability to inflammation and enlargement of all 
these tonsilar or lymphoid "glands" and " kernels" of 
the body generally the old " lymphatic tempera- 

We are, however, now coming to the opinion that 
this so-called "hereditary" narrow nose, short upper 
lip, and high-arched palate are, in a large percentage 
of cases, the result of adenoids in infancy in each suc- 
cessive generation of parents and grandparents. At all 
events, there are now on record cases of children whose 
parents, grandparents, and great -grandparents are 
known to have been nfouth-breathers, and who have 
on that account been sharply watched for the possible 
development of adenoids in early life, and these re- 
moved as soon as they appeared, and they have grown 
up with well-developed, wide nostrils, broad, flat pal- 
ates, and regular teeth, overcoming "hereditary de- 
fect" in a single generation. 

Curiously enough, their origin and ancestral relations 
may have an important practical bearing, even in the 
twentieth century. At the upper end of this curious 
throat-brain canal lies another mass, the so-called pit- 
uitary body. This has been found to exert a profound 
influence over development and growth. Its enlarge- 
ment is attended by giantism and another curious giant 
disease in which the hands, feet, and jaws enlarge enor- 
mously, known as acromegaly. It also pours into the 
blood a secretion which has a powerful effect upon 
both the circulation and the respiration. It is found 
shrunken and wasted in dwarfs. Some years ago it was 


suggested by my distinguished friend, the late Dr. 
Harrison Allen, and myself, that some of the extraor- 
dinary dwarfing and growth-retarding effects of ade- 
noids might be due to a reflex influence exerted on their 
old colleague, the pituitary body. This view has found 
its way into several of the textbooks. Blood is thicker 
than water, and old ancestral vibrations will some- 
times be set up in most unexpected places. 

Now comes the cheerful side of the picture. I should 
have hesitated to draw at such full length and in such 
lugubrious detail the direful possibilities and injurious 
effects of adenoids if its only result could have been to 
arouse apprehensions which could not be relieved. 

Fortunately, just the reverse is the case, and there 
are few conditions affecting the child, so common and 
such a fertile source of all kinds of mischief, and at the 
same time so completely curable, and whose cure will 
be attended by such gratifying improvement on the part 
of the little sufferer. In the first place, as has been said, 
their formation may usually be prevented altogether 
by intelligent and up-to-date hygienic care of the nose 
and the throat. In the second place, even after they 
have occurred and developed to a considerable degree, 
they can be removed by a trifling and almost painless 
operation, and, if taken early enough, all their injurious 
effects overcome. If, however, they have been neglected 
too long, so that the child has passed the eighth or ninth 
year before any interference has been attempted, and 
still more, of course, if it has passed the twelfth or 
thirteenth year, then only a part of the disturbances 
that have been caused can be remedied by their removal. 


So soft and pulpy are these growths, so poorly supplied 
with blood-vessels or nerves, and so slightly connected 
with the healthy tissues below them, that they may, 
in skilled hands, be completely removed by simply 
scraping with a dull surgical spoon (curette) or curved 
forceps, but never anything more knife-like than this. 
In fact, in the first seven years of life, when their re- 
moval is both easiest and will do most good, it is hardly 
proper to dignify the procedure by the name of an 
operation. It is attended by about the same degree 
of risk and of hemorrhage as the extraction of a tooth, 
and by less than half the amount of pain. 

But, trifling and freelfrom danger as is the operation, 
there is nothing in the entire realm of surgery which is 
followed by more brilliant and gratifying results. It 
seems almost incredible until one has seen it in half a 
dozen successive cases. Not merely doctors, but teach- 
ers and nurses, develop a positive enthusiasm for it. 
This was the operation that led to the comical, but 
pathetic, "Mothers' Riots" in the New York schools. 
The word went forth, "The Krishts are cutting the 
throats of your children"; and, with the shameful 
echoes of Kishineff ringing in their ears, the Yiddish 
mothers swarmed forth to battle for the lives of their 

It is no uncommon thing to have a child of seven 
jump three to five inches in height, six to twelve pounds 
in weight, and one to three grades in his schooling, 
within the year following the operation. Ten years 
more of intelligence and hygienic teaching should see 
this scourge of childhood completely wiped out, or at 


least robbed of its possibilities for harm. When this is 
done, at least two-thirds of all cases of deafness, more 
than half of all cases of arrested development, and 
three-fourths of those of backwardness in children will 



ONE of the darling habits of humanity is to dis- 
cover that we are facing a crisis. One could safely 
offer a large prize for a group of ten commencement 
orations, or political platforms, at least a third of which 
did not announce this momentous fact. Either we are 
facing it or it confronts us, and unutterable things will 
happen unless we" gird up our loins,"and vote the right 
' ticket. An interesting feature about these loudly her- 
alded crises is that they hardly ever "crise." The real 
crisis either strikes us so hard that we never know what 
hit us, or is over before we recognize that anything was 
going to happen. And most of our reflections about it 
are after ones trying to explain what caused it. In 
fact, in public affairs, as in medicine, a crisis is a sign of 
recovery. Its occurrence is an indication that nature is 
preparing to throwoff the disease. Nowhere is this truth 
more vividly illustrated than in the tuberculosis situa- 
tion. When, about thirty years ago, the world began to 
awake from its stupor of centuries, and to realize that 
this one great disease alone was killing one-seven ! h of all 
people born under civilization, and crippling as many 
more ; that its killed and wounded every year cast in the 
shade the bloodiest wars ever waged, and that it was ap- 


parently caused by the civilization which it ravaged, 
no wonder that we were appalled at the outlook. 

Here was a disease of civilization, caused by the 
conditions of that civilization. Could it be cured with- 
out destroying its cause and reverting to barbarism ? 
Yet this very apprehension was a sign of hope, a pro- 
mise of improvement. That we were able to feel it was 
a sign that we were shaking off the old fatalistic attitude 
toward disease, as inevitable or an act of Providence. 
It was brought about by the more accurate and sys- 
tematic study of disease. We had long been sadly 
familiar with the fact that death by consumption, by 
"slow decline," by "wasting" or "slow fever," was 
frightfully common. "To fall into a decline" and die 
was one of the standard commonplaces of romantic 
literature. But that was quite different from knowing 
in cold, hard figures and inescapable percentages ex- 
actly how many of the race were killed by it. It is one 
of the striking illustrations of the advantages of good 
bookkeeping. Boards and departments of health had 
just fairly got on their feet and started an accurate 
system of state accounts in matters of deaths and 
births. We were beginning to recognize national 
health as an asset, and to scrutinize its fluctuations 
with keen interest accordingly. 

We may decry statistics as much as we like, but 
when we see the effects of a disease set down in cold 
columns of black and white we have no longer any idea 
of submitting to it as inevitable. We are going to get 
right up and do some fighting. "One-seventh of all 
the deaths" has literally become the war cry of our 


new Holy War against tuberculosis. Still another stir- 
ring phrase of inestimable value in rousing us from our 
torpor was that coined by the brilliant and lovable 
physician-philosopher, Oliver Wendell Holmes: "The 
Great White Plague of the North." This vivid epithet, 
abused as it may have been in later years, was of enor- 
mous service in fixing the public mind on consumption 
as a definite, individual disease, something to be fought 
and guarded against. Before that, we had been in- 
clined to look upon it as just a natural failing of the 
vital forces, a thing that came from within, and was in 
no sense caused frooorwithout. The fair young girl, or 
the delicate boy whose vitality was hardly sufficient 
to carry him through the stern battle of life, under 
some slight shock, or even mental disappointment, 
would sink into a decline, gradually waste away, and 
die. What could be done in such a case, except to bow 
in submission to the inscrutable ways of Providence ? 

It seems incredible now, but such was the light in 
which smallpox was regarded by physicians of the 
Arabian and mediaeval schools : a natural oozing forth 
of "peccant humors" in the blood of the young, a dis- 
agreeable, but perfectly natural, and even necessary, 
process. For if the patient did not get rid of these hu- 
mors either he would die or his growth would be seri- 
ously impaired. Now smallpox has become little more 
than a memory in civilization, and consumption is due 
to follow its example. 

Sanitary pioneers had already begun casting about 
eagerly for light upon the influence of housing, of 
drainage, of food, in the causation of tuberculosis, 


when a new and powerful weapon was suddenly placed 
in their hands by the infant science of bacteriology. 
This was the now world-famous discovery by Robert 
Koch that consumption and other forms of tuberculo- 
sis were due to the attack of a definite bacillus. No 
tubercle bacillus no consumption. 

At first sight this discovery appeared to be anything 
but encouraging. In fact, it seemed to make the situ- 
ation and the outlook even more hopeless. And when 
within a few years it was further demonstrated in rapid 
succession that most of the diseases of the spine in chil- 
dren, of the group of symptoms associated with en- 
larged glands or kernels in the neck and known as 
"scrofula" or struma, most cases of hip-joint disease, 
of white swelling of the knee, a large percentage of 
chronic ulcerations of the skin known as lupus, a com- 
mon form of fatal bowel disease in children, and many 
instances of peritonitis in adults, together with fully 
half of the fatal cases of convulsions in children, were 
due to the activity of this same ubiquitous bacillus, it 
looked as if the enemy were hopelessly entrenched 
against attack. And when it was further found that 
a similar bacillus was almost as common a cause of 
death and disease in cattle, particularly dairy cattle, 
and another in domestic fowls, it looked as if the 
heavens above and the earth beneath were so thickly 
strewn and so hopelessly infested with the germs that 
to war against them, or hope to escape from them, 
was like fighting back the Atlantic tides with a broom. 

But this chill of discouragement quickly passed. 
Our foe had come down out of the clouds, and was 


spread out in battle array before us, in plain sight on 
the level earth. We were ready for the conflict, and 
proposed to " fight it out on this line if it takes all sum- 
mer." It was not long before we began to see joints in 
the enemy's armor and weaknesses in his positions. 
Then, when we lowered our field-glasses and turned to 
count our forces and prepare for the defense, we dis- 
covered with a shock of delighted relief that whole 
regiments of unexpected reinforcements had come up 
while we were studying the enemy's position. These 
new allies of ours were three of the great, silent forces 
of nature, which had fallen into line on either side 
and behind us, without hurry and without excitement, 
without even a bugle-blast to announce their coming. 

The first was the great resisting power and vigor of 
the human organism, which we had gravely underes- 
timated. The second, that power of adaptation to new 
circumstances, including even the attack of infectious 
diseases, which we call "survival of the fittest." The 
third, that great, sustaining, conservative power of 
nature heredity. More cheering yet, these forces 
came, not merely fully armed, but bearing new wea- 
pons fitted for our hands. The vigor and unconquer- 
able toughness of the human animal presented us with 
three glittering weapons, sunshine, food, and fresh air. 

"If the deadly bacillus breaks through the lines, 
put me in the gap ! With these weapons, with this triad, 
I will engage to hurl him back, shattered and broken." 
" Equip your vanguard with them, and the enemy will 
never break the line." 

The survival of the fittest held out to us two weapons 


of strange and curious make, one of them labeled " im- 
munity," the other "quarantine." "Give me a little 
time," she said, "and with the first of these I will make 
seven-tenths of the soldiers in your army proof against 
the spears of the enemy, as Achilles was when dipped 
in the Styx. With the other, surround and isolate every 
roving band of the enemy that you can find ; drive him 
out of the holes and caves in which he lives, into the 
sunlight. Hold him in the open for forty-eight hours, 
and he will die of light-stroke and starvation. Divide 
and conquer ! " 

These reinforcements of ours have proved no mere 
figure of speech. They have won many a battle for us 
already upon the tented field. They have not merely 
made good their promises, but gone beyond them, and 
we are only .just beginning to appreciate their true 
worth, and how absolutely we can rely upon them. 

The first outpost of the enemy was captured with the 
sunshine-food-air weapons, and a glorious victory it 
was, great in itself, and even more important for its 
moral effect and its encouragement for the future. To 
pronounce an illness " consumption " had been from 
time immemorial equivalent to signing a death-war- 
rant. Even the doctors could hardly believe it, when 
the first open-air enthusiasts began to claim that they 
had actually cured cases of genuine consumption. For 
long there was a tendency to mutter in the beard, 
"Well, it was n't genuine consumption, or it would n't 
have got better." 

But after a period of incredulity this gave way to de- 
lighted confidence. The open-air method would cure, 


and did cure, and the patients remained cured for years 
afterward. Our first claims were barely for twenty-five 
or thirty per cent of the threatened victims. Then we 
were able to increase it to fifty per cent ; sixty, seventy, 
and finally eighty were successively reached. But with 
the increase of our power over the cure of this disease 
came a realization of our knowledge of its limitations. 
It quickly proved itself to be no sovereign and uni- 
versal panacea, which would cure all cases, however 
desperate, or however indiscriminately it was applied. 
And emphatically it had to be mixed with brains, on 
the part both of the pjiysician and of the patient. 

In the first place, the likelihood of a cure depended, 
with almost mathematical certainty, upon the earliness 
of the stage at which it was begun. Eight or ten years 
ago the outlook crystallized itself into the form which it 
has practically retained since : of cases put under treat- 
ment in the very early stage, from seventy to ninety per 
cent were practical cures ; of ordinary so-called " first- 
stage" cases, sixty to seventy per cent; second-stage 
cases, or those in whom the disease was well developed, 
thirty to sixty per cent ; and well-advanced cases, fifteen 
to thirty per cent of apparent cures. The crux of the 
whole proposition lies in the early recognition of the dis- 
ease by the physician, and the prompt acceptance of the 
diagnosis by the patient, and his willingness to drop 
everything and fight intelligently and vigorously for 
his life. Physicians are now thoroughly awake on this 
point, and are concentrating their most careful atten- 
tion and study upon methods of recognition at the 
earliest possible stages. At the same time those mag- 


nificent associations for the study and prevention of 
tuberculosis, international, national, state, and local, 
the greatest of which, the International Tuberculosis 
Congress, has just honored America by meeting in 
Washington, are straining every nerve to educate 
the public to understand the importance of recognizing 
the earliest possible symptoms of this disease, no mat- 
ter how trivial they may appear, and making every 
other consideration bend to the fight. 

This new Word of Power, the open-air treatment, 
alone has transformed one of the most hopeless, most 
pathetic, and painful fields of disease into one of the 
most cheerful and hopeful. The vantage-ground won 
is something enormous. No longer need the family phy- 
sician hang back, in dread and horror, from allowing 
himself even to recognize that the slow loss of weight, 
the increasing weakness, the flushed evening cheek, and 
the restless sleep, are signs of this dread malady. In- 
stead of shrinking from pronouncing the patient's 
doom, he knows now that he has everything to gain 
and nothing to lose by promptly warning him of his 
danger, even while it is still problematical. On the 
other hand, the patient need no longer recoil in horror 
when told that he has consumption, and either go 
home to set his house in order and make his will, or 
hunt up another medical adviser who will take a more 
cheerful view of his case. All that he has to do is to 
turn and fight the disease vigorously, intelligently, per- 
sistently, with the certain knowledge that the chances 
are five to one in his favor ; and that 's a good fighting 
chance for any one. 


Even should there be reasonable ground for doubt as 
to the positive nature of the disease, he has nothing to 
lose and everything to gain by taking the steps required 
to cure it. There is nothing magical or irrational, least 
of all injurious, in any way about them. Simply rest, 
abundant feeding, and plenty of fresh air. Even if the 
bacillus has not yet lodged in his tissues, this treatment 
will relieve the conditions of depression from which he 
is suffering, and which would sooner or later render 
him a favorable lodging-place for this omnipresent, 
tiny enemy. 

If he has the disease the treatment will cure it. If he 
has n't got it, it will prevent it; and the gain in vigor, 
weight, and general efficiency will more than pay him 
for the time lost from his business or his study. It al- 
ways pays to take time to put yourself back into a con- 
dition of good health and highest efficiency. 

It was early recognized that the campaign could not 
be won with this weapon alone. Inexpressibly valuable 
and cheering as it was, it had obvious limitations. Th,e 
first of these was the obvious reflection that it was idle 
to cure even eighty per cent of all who actually devel- 
oped tuberculosis, unless something were done to stop 
the disease from developing at all. "Eighty per cent of 
cures," of course, sounds very encouraging, especially 
by contrast with the almost unbroken succession of 
deaths before. But even a twenty per cent mortality 
from such a common disease, if it were to proceed un- 
checked, would make enormous inroads every year 
upon our national vigor. 

Secondly, it was quickly seen that those who recov- 


ered from the disease still bore the scars; that while 
they might recover a fair degree of health and vigor, 
yet they were always handicapped by the time lost and 
the damage inflicted by this slow and obstinate malady ; 
that many of them, while able to preserve good health 
under ideal conditions, were markedly and often dis- 
tressingly limited in the range of their business activi- 
ties for years after, and even for life. Finally, that as 
these cases were followed further and further, it was 
found that even after becoming cured they were sadly 
liable to relapse under some unexpected strain, or to 
slacken their vigilance and drop back into their former 
bad physical habits ; while the conviction began to grow 
steadily upon men who had devoted one, two, or more 
decades to the study of this disease in the localities 
most resorted to for its cure, that the general vigor and 
vitality of these cured consumptives were apt to be not 
of the best ; that their duration of life was not equal to 
the average; and that, even if they escaped a return 
of the disease, they were apt to go down before their 
normal time under the attack of some other malady. 
In short, cure was a poor weapon against the disease 
as compared with prevention. 

But before this, a careful study of the enemy's po- 
sition and investigation of our own resources had 
brought another most important and reassuring fact 
to light, and that is, that while a distressingly large num- 
ber of persons died of tuberculosis, these represented 
only a comparatively small percentage of all who had 
actually been attacked by the disease. One of the rea- 
sons why consumption had corne to be regarded as 


such a deadly disease was that the milder cases of it 
were never recognized. It was, and is yet, a common 
phrase in the mouths of both the laity and of the medi- 
cal profession: "He was seriously threatened with 
consumption " ; " She came very near falling into 
a decline," but they recovered. If they did n't die 
of it, it wasn't "real" tuberculosis. Now we have 
changed all that, and have even begun to go to the op- 
posite extreme, of declaring with the German experts, 
"Jeder Mann ist am ende ein bischen tuberkulose." 
(Every one is some time or another a little bit tuber- 
culous.) This sounds appalling at first hearing, but as 
a matter of fact it is immensely encouraging. Our first 
suspicion of it came from the records of that gruesome, 
but pricelessly valuable, treasure-house of solid facts 
in pathology the post-mortem room, the dead-house. 
Systematic examinations of all the bodies brought to 
autopsy in our great hospitals and elsewhere revealed 
at first thirty, then, as the investigation became more 
minute and skillful, forty, sixty, seventy-five per cent 
of scars in the apices of the lungs, remains of healed cav- 
ities, infected glands, or other signs of an invasion by 
the tubercle bacillus. Of course, the skeptic challenged 
very properly at once : 

" But how do you know that these masses of chalky- 
material, these enlarged glands, are the result of tuber- 
culosis ? They may be due to some half-dozen other 

Almost before the question was asked a test was 
made by the troublesome but convincing method of cut- 
ting open these scars, dividing these enlarged glands, 


scraping materials out of their centre, and injecting 
them into guinea pigs. Result : from thirty to seventy 
per cent of the guinea pigs died of tuberculosis. In 
other cases it was not necessary to inoculate, as scrap- 
ings or sections from these scar-masses showed tubercle 
bacilli, clearly recognizable by their staining reaction. 

Here, then, we have indisputable evidence of the 
fact that the tubercle bacillus may not only enter some 
of the openings of the body, the nostrils, the mouth, 
the lungs, but may actually form a lodgment and a 
growth-colony in the lungs themselves, and yet be 
completely defeated by the antitoxic powers of the 
blood and other tissues of the body, prevented from 
spreading throughout the rest of the lung, most of the 
invaders destroyed, and the crippled remnants impris- 
oned for life in the interior of a fibroid or chalky mass. 

It gave one a distinct shock at the meeting of the 
British Medical Association devoted to tuberculosis, 
some ten years ago, to hear Sir Clifford Allbutt, one 
of the most brilliant and eminent physicians of the 
English-speaking world, remark, on opening his 
address, " Probably most of us here have had tuber- 
culosis and recovered from it." 

Here is evidently an asset of greatest and most prac- 
tical value, which changes half the face of the field. In- 
stead of saving, as best we may, from half to two-thirds 
of those who have allowed the disease to get the upper 
hand and begin to overrun their entire systems, it 
places before us the far more cheering task of building 
up and increasing this natural resisting power of the 
human body, until not merely seventy per cent of all 


who are attacked by it will throw it off, but eighty, 
eighty-five, ninety ! We can plan to stop consumption 
by preventing the consumptive. A very small additional 
percentage of vigor or of resisting power such as 
could be produced by but a slight improvement in the 
abundance of the food-supply, the lighting and venti- 
lating of the houses, the length and " fatiguingness " of 
the daily toil might be the straw which would be 
sufficient to turn the scale and prevent the tuberculous 
individual from becoming consumptive. 

Here comes in one of the most important and valu- 
able features of our splendid sanatorium campaign 
for the cure of tuberculosis, and that is the nature of 
the methods employed. If we relied for the cure of the 
disease upon some drug, or antitoxin, even though we 
might save as many lives, the general reflex or second- 
ary effect upon the community might not be in any 
way beneficial ; at best it would probably be only nega- 
tive. But when the only " drugs " that we use are fresh 
air, sunshine, and abundant food, and the only anti- 
toxins those which are bred in the patient's own body ; 
when, in fact, we are using for the cure of consump- 
tion precisely those agencies and influences which will 
prevent the well from ever contracting it, then the whole 
curative side of the movement becomes of enormous 
racial value. The very same measures that we rely 
upon for the cure of the sick are those which we would 
recommend to the well, in order to make them stronger, 
happier, and more vigorous. 

If the whole civilized community could be placed 
upon a moderate form of the open-air treatment, it 


would be so vastly improved in health, vigor, and effi- 
ciency, and saved the expenditure of such enormous 
sums upon hospitals, poor relief, and sick benefits, that 
it would be well worth all that it would cost, even if 
there were no such disease as tuberculosis on earth. 

This is coming to be the real goal, the ultimate hope 
of the far-sighted leaders in our tuberculosis campaign, 
to use the cure of consumption as a lever to raise to 
a higher plane the health, vigor, and happiness of the 
entire community. 

Enormously valuable as is the open-air sanatorium 
as a means of saving thousands of valuable and beloved 
lives, its richest promise lies in its function as a school 
of education for the living demonstration of methods 
by which the health and happiness of the ninety-five 
per cent of the community who never will come within 
its walls may be built up. Every consumptive cured 
in it goes home to be a living example and an enthusi- 
astic missionary in the fresh-air campaign. The ulti- 
mate aim of the sanatorium will be to turn every farm- 
house, every village, every city, into an open-air resort. 
When it shall have done this it will have fulfilled its 

Our plan of campaign is growing broader and more 
ambitious, but more hopeful, every day. All we have 
to do is to keep on fighting and use our brains, and vic- 
tory is certain. Our Teutonic fellow soldiers have 
already nailed their flag to the mast with the inscrip- 
tion : 

"No more tuberculosis after 1930!" 

So much for the serried masses of the centre of our 


anti-tuberculosis army, upon which we depend for the 
heavy, mass fighting and the great frontal attacks. But 
what of the right and the left wings, and the cloud of 
skirmishers and cavalry which is continually feeling 
the enemy's position and cutting off his outposts ? 
Upon the right stretch the intrenchments of the bac- 
teriologic brigade, with the complicated but marvel- 
ously effective weapons of precision given us by the 
discovery of the definite and living cause of the dis- 
ease, the Bacillus tuberculosis. Upon the left wing lie 
camp after camp of native regiments, whose loyalty 
until of very recent years was more than doubtful, 
heredity, acquired immunity, and the so-called im- 
provements of modern civilization, steam, electricity, 
and their kinsmen. 

To the artillerymen of the bacteriologic batteries ap- 
pears to have been intrusted the most hopeless task, 
the forlorn hope, the total extermination of a foe so 
tiny that he had to be magnified five hundred times 
before he was even visible, and of such countless myr- 
iads that he was at least a billion times as numerous 
as the human race. But here again, as in the centre of 
the battle-line, when we once made up our minds to 
fight, we were not long in discovering points of attack 
and weapons to assault him with. 

First, and most fundamental of all, came the consol- 
ing discovery that though there could be no consump- 
tion without the bacillus, not more than one individual 
in seven, of fair or average health, who was exposed 
to its attack in the form of a definite infection, suc- 
cumbed to it; and that, as strongly suggested by the 


post-mortem findings already described, even those 
who developed a serious or fatal form of the disease 
had thrown off from five to fifteen previous milder or 
slighter infections. So that, to put it roughly, all that 
would be necessary practically to neutralize the inju- 
riousness of the bacillus would be to prevent about 
one-twentieth of the exposures to its invasion which 
actually occurred, The other nineteen-twentieths 
would take care of themselves. The bacilli are not the 
only ones who can be numbered in their billions. If 
there are billions of them there are billions of us. We 
are not mere units scarcely even individuals ex- 
cept in a broad and figurative sense. We are confedera- 
cies of billions upon billions of little, living animalcules 
which we call cells. These cells of ours are no Sun- 
day-school class. They are old and tough and cunning 
to a degree. They are war-worn veterans, carrying the 
scars of a score of victories written all over them. They 
are animals; bacteria, bacilli, micrococci, and all their 
tribe are vegetables. The daily business, the regular 
means of livelihood of the animal cell for fifteen mil- 
lions of years past has been eating and digesting the 
vegetable. And all that our body-cells need is a little 
intelligent encouragement to continue this perform- 
ance, even upon disease germs; so that we need n't 
be afraid of being stampeded by sudden attack. 

The next cheering find was that the worst enemies 
of the bacillus were our best friends. Sunlight will kill 
them just as certainly as it will give us new life. 
The germs of tuberculosis will live for weeks and even 
months in dark, damp, unventilated quarters, just pre- 


cisely such surroundings as are provided for them in 
the inside bedrooms of our tenements, and the dark, 
cellar-like rooms of many a peasant's cottage or farm- 
house. In bright sunlight they will perish in from three 
to six hours ; in bright daylight in less than half a day. 
This is one of the factors that helps to explain the ap- 
parent paradox, that the dust collected from the floors 
and walls of tents and cottages in which consumptives 
were treated was almost entirely free from tuberculous 
bacilli, while dust taken from the walls of tenement 
houses, the floors of street-cars, the walls of churches 
and theatres in New york City, was found to be simply 
alive with them. One of the most important elements 
in the value of sunlight in the treatment of consump- 
tion is its powerful germicidal effect. 



/CLOSELY allied to the discovery that sunlight and 
\-J fresh air are fatal to the microorganisms of tuber- 
culosis came the consoling fact that these bacilli, though 
most horribly ubiquitous and apparently infesting both 
the heavens above and the earth beneath, had neither 
wings nor legs, and were absolutely incapable of pro- 
pelling themselves a fraction of an inch. They do not 
move they have to be carried. More than this, like 
all other disease-germs, while incredibly tiny and in- 
finitesimal, they have a definite weight of their own, 
and are subject to the law of gravity. They do not flit 
about hither and thither in the atmosphere, thistle- 
down fashion, but rapidly fall to the floor of whatever 
room or receptacle they may be thrown in. And the 
problem of their transference is not that of direct carry- 
ing from one victim to the next, but the intermediate 
one of infected materials, such as are usually associated 
with visible dust or dirt. In short, keep dust or dirt 
from the floor, out of our food, away from our fingers 
or clothing or anything that can be brought to or near 
the mouth, and you will practically have abolished the 
possibility of the transference of tuberculosis. The 
consumptive himself is not a direct source of danger. 


It is only his filthy or unsanitary surroundings. Put a 
consumptive, who is careful of his sputum and cleanly 
in his habits, in a well-lighted, well- ventilated room, or, 
better still, out of doors, and there will be exceedingly 
little danger of any other member of his family or of 
those in the house with him contracting the disease. 
Wherever there is dirt or dust there is danger, and 
there almost only. Thorough and effective house- 
reform not merely in tenements, alas ! but in myr- 
iads of private houses as well would abolish two- 
thirds of the spread of tuberculosis. 

It is not necessary to isolate every consumptive in 
order to stop the spread of the disease. All that is re- 
quisite is to prevent the bacilli in his sputum from 
reaching the floor or the walls, to have both the latter 
well lighted and aired, and, if possible, exposed to direct 
sunlight at some time during the day, and to see that 
dust from the floor is not raised in clouds by dry sweep- 
ing so as to be inhaled into the lungs or settle upon food, 
fingers, or clothing, and that children be not allowed 
to play upon such floors as may be even possibly con- 
taminated. These precautions, combined with the 
five-to-one resisting power of the healthy human or- 
ganism, will render the risk of transmission of the dis- 
ease an exceedingly small one. To what infinitesimal 
proportions this risk can be reduced by intelligent and 
strict sanitation is illustrated by the fact, already al- 
luded to, of the almost complete germ-freeness of the 
dust from walls and floors of sanitorium cottages, and 
by the even more convincing and conclusive practical 
result, that scarcely a single case is on record of the 


transmission of this disease to a nurse, a physician, or 
a servant, or other employee in an institution for its 

There is absolutely no rational basis for this panic- 
stricken dread of an intelligent, cleanly consumptive, or 
for the cruel tendency to make him an outcast and raise 
the cry of the leper against him : " Unclean ! Unclean !" 

It cannot be too strongly emphasized that consump- 
tion is transmitted by way of the floor; and if this relay- 
station be kept sterile there is little danger of its trans- 
mission by other means. 

Practically all that is needed to break this link is the 
absolute suppression of what is universally and over- 
whelmingly regarded as not merely an unsanitary and 
indecent, but a filthy, vulgar, and disgusting habit 
promiscuous expectoration. There is nothing new or 
unnatural in this repression, this tabu on expectoration. 
In fact, we are already provided with an instinct to 
back it. In every race, in every age, in every grade of 
civilization, the human saliva has been regarded as the 
most disgusting, the most dangerous and repulsive of 
substances, and the act of spitting as the last and deep- 
est sign of contempt and hatred ; and if directed toward 
an individual, the deadliest and most unbearable insult, 
which can be wiped out only by blood. Primitive litera- 
ture and legend are full of stories of the poisonousness 
of human saliva and the deadliness of the human bite. 
It was the "bugs" in it that did it. It is most interest- 
ing to see how science has finally, thousands of years 
afterward, shown the substantial basis of, and gone 
far to justify, this instinctive horror and loathing. 


Not merely are the fluids of the human mouth liable 
to contain the tubercle bacillus, and that of diphtheria, 
of pneumonia, and half a dozen other definite dis- 
orders, but they are in perfectly healthy individuals, 
especially where the teeth are in poor condition, 
simply swarming with millions of bacteria of every 
sort, some of them harmless, others capable of setting 
up various forms of suppuration and septic inflam- 
mation if introduced into a wound, or even if taken 
into the stomach. Even if there were no such disease 
as tuberculosis a campaign to stamp out promiscuous 
expectoration would be well worth all it cost. 

Of course, as a counsel of perfection, the ideal pro- 
cedure would be promptly to remove each consump- 
tive, as soon as discovered, from his house and place 
him in a public sanatorium, provided by the state, 
for the sajse of removing him from the conditions 
which have produced his disease, of placing him under 
those conditions which alone can offer a hopeful pros- 
pect of cure, and of preventing the further infection 
of his surroundings. The only valid objections to such 
a plan are those of the expense, which, of course, 
would be very great. It would be not merely best, 
but kindest, for the consumptive himself, for his im- 
mediate family, and for the community. And enor- 
mous as the expense would be, when we have become 
properly aroused and awake to the huge and almost 
incredible burden which this disease, with its one 
hundred and fifty thousand deaths a year, is now 
imposing upon the United States, five times as 
great as that of war or standing army in the most mili- 


tary-mad state in Christendom, the community 
will ultimately assume this expense. So long, however, 
as our motto inclines to remain, "Millions for cure, 
but not one cent for prevention," we shall dodge this 

There can be no question but that each state and 
each municipality of more than ten thousand inhab- 
itants ought to provide an open-air camp or colony of 
sufficient capacity to receive all those who are willing 
to take the cure but unable to meet the expense of a 
private institution; and, also, some institution of 
adequate size, to which could be sent, by process of 
law, all those consumptives who, either through per- 
versity, or the weakness and wretchedness due to their 
disease, or the apathy of approaching dissolution, 
fail or are unable to take proper precautions. 

When we remember that the careful investigations 
of the various dispensaries for the treatment of tuber- 
culosis in our larger cities, New York, Boston, Cleve- 
land, report that on an average twenty to thirty per 
cent of all children living in the same room or apart- 
ment with a consumptive member of their family are 
found to show some form of tuberculosis, it will be 
seen how well worth while, from every point of view, 
this provision for the removal and sanatorium treat- 
ment of the poorer class of these unfortunates would 
be. These dispensaries now have, as a most important 
part of their campaign against the disease, one or 
more visiting nurses, who, whenever a patient with 
tuberculosis is brought into the dispensary, visit him 
in his home, show him how to ventilate and light 


his rooms as well as may be, give practical demon- 
strations of the methods of preventing the spread of 
the disease, advise him as to his food, and see that 
he is supplied with adequate amounts of milk and eggs, 
and, finally, round up all the children of the family 
and any adults who are in a suspicious condition of 
health, and bring them to the dispensary for exami- 
nation. Distressing as are these findings, reaching 
in some cases as high as fifty and sixty per cent of 
the children, they have already saved hundreds of 
children, and prevented hundreds of others from 
growing up crippled or handicapped. 

It must be remembered that the tubercle bacillus 
causes not merely disease of the lungs in children but 
also a large majority of the crippling diseases of the 
bones, joints, and spine, together with the whole group 
of strumous or scrofulous disorders, and a large group 
of intestinal diseases and of brain lesions, resulting 
in convulsions, paralysis, hydrocephalus, and death. 
The battle-ground of the future against tuberculosis 
is the home. 

We speak of the churchyard as "haunted," and we 
recoil in horror from the leper-house or the cholera- 
camp. Yet the deadliest known hotbed of horrors, 
the spawning ground of more deaths than cholera, 
smallpox, yellow fever, and the bubonic plague com- 
bined, is the dirty floor of the dark, unventilated 
living-room, whether in city tenement or village 
cottage, where children crawl and their elders spit. 

It is scarcely to the credit of our species that for 
convincing, actual demonstrations of what can be 


done toward stamping out tuberculosis, by measures 
directed against the bacillus alone, we are obliged to 
turn to the lower animals. By a humiliating paradox 
we are never quite able to put ourselves under those 
conditions which we know to be ideal from a sanitary 
point of view. There are too many prejudices, too 
many vested interests, too many considerations of 
expense to be reckoned with. But with the lower 
animals that come under our care we have a clear 
field, free from obstruction by either our own preju- 
dices or those of others. In this realm the stamping 
out of tuberculosis is not merely a rosy dream of the 
future but an accomplished fact, in some quarters 
even an old story. Two illustrations will suffice, one 
among domestic animals, the other among wild ani- 
mals in captivity. The first is among pure-bred dairy 
cattle, the pedigreed Jerseys and Holsteins. No sooner 
did the discovery of the bacillus provide us with a 
means of identification, than the well-known " perl- 
sucht" of the Germans, or "grapes" of the English 
veterinarians both names being derived from the 
curious rounded masses or nodules of exudate found 
in the pleural cavity and the peritoneum (around the 
lungs and the bowels), and supposed to resemble 
pearls and grapes respectively were identified as< 
tuberculosis, and cows were found very widely infected 
with it. This unfortunately still remains the case with 
the large mass of dairy cattle. But certain of the more 
intelligent breeders owning valuable cattle proceeded 
to take steps to protect them. 

The first step was to test their cows with tuberculin* 


promptly weeding out and isolating all those that re- 
acted to the disease. It was at first thought necessary to 
slaughter all these at once. But it was later found that, 
if they were completely isolated and prevented from 
communicating the disease to others, this extreme mea- 
sure was necessary only with those extensively diseased. 
The others could be kept alive, and if their calves were 
promptly removed as soon as born, and fed only upon 
sterilized or perfectly healthy milk, they would be free 
from the disease. And thus the breeding-life of a par- 
ticularly valuable and high-bred animal might be pro- 
longed for a number jpi years. They must, however, 
be kept in separate buildings and fields, and preferably 
upon a separate farm from the rest of the herd. 

Those cows found healthy were given the best of 
care, including a marked diminution of the amount of 
housing or confinement in barns, and were again tested 
at intervals of six months, several times, to weed out 
any others which might still have the infection in their 
systems. In a short time all signs of the disease disap- 
peared, and no other cases developed in these herds 
unless fresh infection was introduced from without. 
To guard against this, each farm established a quaran- 
tine station, where all new-bought animals, after having 
been tested with tuberculin and shown to be free from 
reaction, are kept for a period of at least a year, for 
careful observation and study, before being allowed 
to mix with the rest of the herd. It is now a common 
requirement among intelligent breeders of pedigreed 
cattle to demand, as a formal condition of sale, their 
submission to the tuberculin test, or the certificate of 


a competent veterinarian that the animal has been so 
tested without reacting. Protected herds have now been 
in existence under these conditions, notably in Den- 
mark, where the method was first reduced to a system 
under the able leadership of Professor Bang, of Copen- 
hagen, for ten years with scarcely a single case of tuber- 
culosis developing. Only a fraction of one per cent of 
calves from the most diseased mothers are born diseased. 

Not only is the method spreading rapidly among 
the more intelligent class of breeders, but many pro- 
gressive countries of Europe and states of our Union 
require the passing of the tuberculin test as a requisite 
to the admission within their borders of cattle intended 
for breeding purposes. So that, while the problem is 
still an enormous one, it is now confidently believed 
that complete eradication of bovine tuberculosis is only 
a question of time. 

The other instance furnishes a much more crucial 
test, as it is carried out upon wild animals under the 
unfavorable conditions of captivity in a strange climate, 
like our slum-dwellers from sunny Italy, and comes 
home to us more closely in many respects, inasmuch 
as it is concerned with our nearest animal relatives 
on the biological side monkeys and apes, in zoologi- 
cal gardens. 

Tuberculosis is a perfectly frightful scourge to these 
unfortunate captives, causing not infrequently thirty, 
fifty, and even sixty per cent of the deaths. This, how- 
ever, is only in keeping with their frightful general mor- 
tality. The collection of monkeys in the London Zoo, 
for instance, some fifteen years ago, was absolutely 


exterminated by disease and started over afresh every 
three years, a death-rate of thirty-five per cent per an- 
num as compared with our human rate of about two 
per cent per annum. Here, it would seem, was an in- 
stance where there was little need to call in the bacillus. 
Brought from a tropical climate to one of raw, damp 
fog and smoke, from the freedom of the air-roads 
through the tree-tops to the confinement of dismal and 
often dirty cages in a stuffy, overheated house, con- 
demned to a diet which at best could be but a feeble 
and far-distant imitation of their natural food, it 
seemed little wonder j;hat they " jes' natcherly pined 
away an' died." 

But let the results speak. A thorough system of quar- 
antine was enforced, beginning with one of the Vienna 
gardens, and finally reaching one of its most brilliant 
and successful exemplifications in our own New York 
Zoological Gardens in the Bronx. All animals pur- 
chased or donated were tested with tuberculin, and 
those that reacted were either painlessly destroyed or 
disposed of. Those which appeared to be immune were 
kept in a thoroughly healthy, sanitary quarantine sta- 
tion for six months or a year, and again tested by tuber- 
culin before being introduced into the cages. The origi- 
nal stock of monkeys was treated in the same manner 
or else destroyed completely, and the houses and cages 
thoroughly cleaned and sterilized or new ones con- 
structed. Keepers employed in the monkey-house were 
carefully tested for signs of tuberculosis, and rejected 
or excluded if any appeared. Signs were posted for- 
bidding any expectoration or feeding of the animals 


(which latter is often done with nuts or fruit which had 
been cracked or bitten before being handed to the 
monkeys) by the general public, and these rules were 
strictly enforced. 

At the same time the houses were thoroughly ven- 
tilated and exposed to sunlight as much as possible, and 
the animals were turned out into open air cages when- 
ever the weather would possibly permit. As a result the 
mortality from tuberculosis promptly sank from thirty 
per cent to five or six per cent. In our Bronx Zoo, for 
instance, it has become decidedly rare as a cause of 
death in monkeys, no case having occurred in the mon- 
key-house for eighteen months past. What is even 
more gratifying, the general mortality declined also, 
though in less proportion, so that, instead of losing 
twenty-five to thirty per cent of the animals in the 
house every year, a mortality of ten to fifteen per cent 
is now considered large. 

And to think that we might achieve the same results 
in our own species if we would only treat ourselves as 
well as we do our monkey captives ! To " make a mon- 
key of one's self" might have its advantages from a 
sanitary point of view. 

" But this method," some one will remind us, " would 
silence only a part of the enemy's infection batteries." 
Even supposing that we could prevent the spread of the 
disease from human sources, what of the animal con- 
sumptives and their deadly bacilli ? If the milk that we 
drink, and the beef, pork, and poultry that we eat, are 
liable to convey the infection, what hope have we of 
ever stopping the invasion ? 


The question is a serious one. But here again a thor- 
ough and careful study of the enemy's position has 
shown the danger to be far less than it appeared at first 
sight. Even bacilli have what the French call " the de- 
fects of their virtues." Their astonishing and most dis- 
quieting powers of adjustment, of accommodation to 
the surroundings in which they find themselves, namely, 
the tissues and body-fluids of some particular host 
whom they attack, bring certain limitations with them. 
Just in so far as they have adjusted themselves to live 
in and overcome the opposition of the body-tissues of a 
certain species of animals, just to that degree they have 
incapacitated themselves to live in the tissues of any other 

Some of the most interesting and far-reachingly im- 
portant work that has been done in the bacteriology of 
tuberculosis of late years has concerned itself with the 
changes that have taken place in different varieties and 
strains of tubercle bacilli as the result of adjusting them- 
selves to particular environments. The subject is so 
enormous that only the crudest outlines can be given 
here, and so new that it is impossible to announce any 
positive conclusions. But these appear to be the domi- 
nant tendencies of thought in the field so far. 

Though nearly all domestic animals and birds, and 
a majority of wild animals under captivity, are sub- 
ject to the attack of tuberculosis, practically all the 
infections hitherto studied are caused by one of three 
great varieties or species of the tubercle bacillus : the 
human, infesting our own species ; the bovine, attacking 
cattle; and the avian, inhabiting the tissues of birds, 


especially the domestic fowl. These three varieties or 
species so closely resemble one another that they were 
at one time regarded as identical, and we can well re- 
member the wave of dismay which swept over the 
medical world when Robert Koch announced that the 
" perlsucht " of cattle was a genuine and unquestioned 
tuberculosis due to an unmistakable tubercle bacillus. 
But as these varieties were thoroughly and carefully 
studied, it was soon found that they presented definite 
marks of differentiation, until now they are universally 
admitted to be distinct varieties, each with its own life 
peculiarities, and, according to some authorities, even 
distinct species. 

"But," we fancy we hear some one inquire impa- 
tiently, " what do those academic, technical distinctions 
matter to us ? Whether the avian tuberculosis germ is 
a variety or a true species may be left to the taxono- 
mists, but it is of no earthly importance to us." 

On the contrary, it is of the greatest importance. For 
the distinctive feature about a particular species of 
parasite is that it will live and flourish where another 
species will die, and, vice versa, will die in surround- 
ings where its sister species might live and thrive. 

One of the first differences found to exist among 
these three types of bacteria was the extraordinary 
variation in their power of attacking different animals. 
For instance, while the guinea-pig and the rabbit could 
be readily inoculated with human bacilli, they could 
only be infected with difficulty by cultures of the bovine 
bacillus ; while the only animal that could be inoculated 
at all with the avian or bird bacillus was the rabbit, 


and he only occasionally. In fact, bacteriologists soon 
came to the consoling conclusion that the avian bacillus 
might be practically disregarded as a source of danger 
to human beings, so widely different were the condi- 
tions in their moist and moderately warm tissues to 
those of the dry and superheated tissues of the bird 
to which it had adjusted itself for so many generations. 

And next came the bold pronunciamento of no less 
an authority than Koch himself, that the bovine bacil- 
lus also was so feebly infective to human beings that it 
might be practically disregarded as a source of danger. 
This promptly split tjae bacteriologists of the world 
into two opposing camps, and started a warfare which 
is still being waged with great vigor. As the question 
is still under hot dispute by even the highest authorities, 
it is, of course, impossible to pronounce any definite con- 
clusions. But the net result to date appears to be that 
while Koch made a serious error of judgment in de- 
claring that meat and milk as a source of danger to 
human beings of tuberculosis might be disregarded, 
yetffor practical purposes, his position is, in the main, 
correct : the actual danger from the bovine bacillus to 
human beings is relatively small. 

There was nothing whatever improbable, in the first 
place, in the correctness of Koch's position. 

It is one of the few consoling facts, well known to all 
students of comparative pathology or the diseases of 
the different species of animals, how peculiarly special- 
ized they are in the choice of their diseases, or, per- 
haps, to put it more accurately, how particular and re- 
stricted disease-germs are in their choice of a host. For 


instance, out of twenty-eight actually infectious diseases 
which are most common among the domestic animals 
and man, other than tuberculosis, only one rabies 

is readily communicable to more than three species ; 
only three anthrax, tetanus, and foot-and-mouth 
disease are communicable to two species ; while the 
remainder are almost absolutely confined to one species, 
even though this be thrown into closest contact with 
half a dozen others. 

Again, we have half a dozen similar instances in the 
case of tuberculosis itself. The horse and the sheep, 
for instance, are both most intimately associated with 
cattle, pastured in the same fields, fed upon the same 
food, and yet tuberculosis is almost unknown in sheep 
and decidedly uncommon in horses, and when it does 
occur in them is from a human source. The goat is 
almost equally immune from both human and bovine 
forms, while the cat and the dog, although developing 
the infection with a low degree of frequency, almost 
invariably trace that infection to a human source. 

There is, therefore, no a priori reason whatever why 
we should be any more susceptible to bovine tubercu- 
losis than the remainder of the domestic animals. It is 
only fair to say, however, that the animal whose diet 

and appetite most closely resembles ours, the hog, 
is quite fairly susceptible to bovine tuberculosis if fed 
upon the milk or meat of tuberculous cattle. 

Next came the particularly consoling fact that al- 
though nothing has been more striking than the great 
increase in the amounts of meat and milk consumed by 
the mass of the community during our last twenty- 


years' progress in civilization, this has been accompa- 
nied not by any increase of tuberculosis, but by a dimi- 
nution of from thirty-five to forty-five per cent. The 
allegation so frequently made that there has been an 
increase in the amount of infantile tuberculosis has 
been shown, upon careful investigation by Shennan of 
Edinburgh, Guthrie of London, Kossel in Germany, 
Comby in France, Bovaird in New York, and others, 
to be practically without foundation. 

Then, while repetitions of Koch's experiment, upon 
which his announcement was based, of inoculating 
calves and young cattle ^vith human bacilli have proved 
that a certain number of them can be, under appropriate 
circumstances, made to develop tuberculosis, that nunv 
ber has never been a large percentage of the animals 
tested, and in many cases the infection has been a local 
one, or of a mild type, which has resulted in recovery. 
Lastly, while a number of bacilli, with bovine culture 
and other characteristics, have been recovered from 
the bodies of children dying of tuberculosis, and these 
bacilli have proved virulent to calves when injected 
into them, yet, as a matter of historical fact, the actual 
number of instances in which children or other human 
beings have been definitely proved to have contracted 
the disease from the milk of a tuberculous cow is still 
exceedingly and encouragingly small. A careful study 
of the entire literature of the past twenty years, some 
three years ago, revealed only thirty-seven cases ; and of 
these thirty-seven Koch's careful investigations have 
since disproved the validity of nine. ^ 

On the other hand, it is anything but safe to accept 


Koch's practical dictum and neglect the meat and 
milk of cattle as a source of danger in tuberculosis. 
First, because the degree of our immunity against the 
bovine bacilli is still far from settled ; and, second, be- 
cause, while bacteriologists are fairly agreed that the 
avian, the bovine, and the human represent three dis- 
tinct and different variations, if not species, of the bacil- 
lus, they are almost equally agreed that they are prob- 
ably the descendants of one common species, which 
may possibly be a bacillus commonly found upon 
meadow grasses, particularly the well-known timothy, 
and hence very frequently in the excreta of cattle, and 
known as the grass bacillus or dung bacillus of Mceller. 
This bacillus has all the staining, morphological, and 
even growth characteristics of the tubercle bacillus ex- 
cept that it produces only local irritation and little nod- 
ular masses, if injected into animals. Our knowledge 
of its existence is, however, of great practical import- 
ance, inasmuch as it warned us that in our earlier 
studies of the bacilli contained in milk and butter we 
have been mistaking this organism for a genuine tuber- 
cle bacillus. As a consequence, of late years our tests 
for the presence of tubercle bacilli in milk are made not 
only by searching for the organism with the microscope, 
but also by injecting the centrifugated sediment of the 
infected milk into guinea pigs, to see if it proves infec- 
tious. Many of our earlier statements as to the pre- 
sence of tubercle bacilli in milk and butter are now 
invalidated on this account. 

Not only are the three varieties of tubercle bacilli 
probably of common origin, but they may, under cer- 


tain peculiar conditions, be transformed into one an- 
other, or, at least, enabled to live under the conditions 
favorable to one another. This was shown nearly fif- 
teen years ago by the ingenious experiments of Nocard, 
the great veterinary pathologist. He took a culture of 
bovine bacilli, which were entirely harmless to fowls, 
and, inclosing them in a collodion capsule, inserted 
them into the peritoneal cavity of a hen. The collodion 
capsule permitted the fluids of the body to enter and 
provide food for the bacilli, but prevented the admis- 
sion of the leucocytes to attack and destroy them. 
After several weeks the capsule was removed, the ba- 
cilli found still alive, and transferred to another capsule 
in another fowl. When this process had been repeated 
some five or six times, the last generation of bacilli was 
injected into another fowl, which promptly developed 
tuberculosis, showing that by gradually exposing the 
bacilli for successive generations to the high tempera- 
ture of the bird's body (from five to fifteen degrees 
above that of the mammal), they had become accli- 
mated, as it were, and capable of developing. So that 
it is certainly quite conceivable that bovine bacilli 
introduced in milk or meat might manage to find a 
haven of refuge or lodgment in some out-of-the-way 
gland or tissue of the human body, and there avoid 
destruction for a sufficiently long time to become ac- 
climated and later infect the entire system. 

This is the method which several leaders in bacteri- 
ology, including Behring (of antitoxin fame), believe 
to be the principal source and method of infection of 
the human species. The large majority, however, of 


bacteriologists and clinicians are of the opinion that 
ninety per cent of all cases of human tuberculosis are 
contracted from some human source. So that, while 
we should on no account slacken our fight against tu- 
berculosis in either cattle or birds, and should encour- 
age in every way veterinarians and breeders to aim for 
its total destruction, a consummation which would 
be well worth all it would cost them, purely upon eco- 
nomic grounds, just as the extermination of human 
tuberculosis would be to the human race, yet we 
need not bear the burden of feeling that the odds 
against us in the fight for the salvation of our own 
species are so enormous as they would be, had we no 
natural protection against infection from animals and 

The more carefully we study all causes of tubercu- 
losis in children, the larger and larger percentage of 
them do we find to be clearly traceable to infection 
from some member of the family or household. In 
Berlin, for instance, Kayserling reports that seventy 
per cent of all cases discovered can be traced to direct 
infection from some previous human case. 

Lastly, what of the left wing of our army of extermi- 
nation, composed of those light-horse auxiliaries the 
general progress and new developments of civilization, 
and the net results upon the individual of the experi- 
ences of his ancestors, which we designate by the term 
"heredity" ? For many years we were in serious doubt 
how far we could depend upon the loyalty of this group 
of auxiliaries, and many of the faint-hearted among us 
were inclined to regard their sympathies as really 


against us rather than with us, and prepared to see 
them desert to the enemy at any time. It was pointed 
out, as of great apparent weight, that consumption was 
decidedly and emphatically a disease of civilization; 
that it was born of the tendency of men to gather them- 
selves into clans and nations and crowd themselves 
into villages and those hives of industry called cities ; 
that the percentage of deaths from tuberculosis in any 
community of a nation or any ward of a city was high in 
direct proportion to the density of its population ; and 
that the whole tendency of civilization was to increase 
this concentration, this congestion of ground space, 
this piling of room upon room, of story upon story. 
How could we possibly, in reason, expect that the influ- 
ences which had caused the disease could help us to 
cure it? 

But the improbable has already happened. Never 
has there been a more rapid and extraordinary growth 
of our great cities as contrasted with our rural districts, 
never has there been a greater concentration of popula- 
tion in restricted areas than during the past thirty-five 
years. And yet, the prevalence of tuberculosis in that 
time, in all civilized countries of the earth, has shown 
not only no increase, but a decrease of from thirty-Jive 
to fifty per cent. To-day the world power which has the 
largest percentage of its inhabitants gathered within 
the limits of its great cities, England, has the lowest 
death-rate in the civilized world from tuberculosis, al- 
though closely pressed within the last few years by the 
United States, whose percentage of urban population 
is almost equally large, while England's sister island, 


Ireland, with one of the highest percentages of rural 
and the lowest of urban population, has one of the 
highest death-rates from tuberculosis, and one which 
is, unfortunately, increasing. 

The real cure for the evils of civilization would ap- 
pear to be more civilization, or, better, perhaps, higher 
civilization. Nor are these exceptional instances. Take 
practically any city, state, or province in the civilized 
world, which has had an adequate system of recording 
all births and deaths for more than thirty years, and 
you will find a decrease in the percentage of deaths 
from tuberculosis in that time of from twenty to forty 
per cent. The city of New York's death-roll, for in- 
stance, from tuberculosis, per one thousand living, is 
some thirty-five per cent less than it was thirty years 
ago. So that our fight against the disease is beginning 
to bear fruit already. As Osier puts it, we run barely 
half the risk of dying of tuberculosis that our parents 
did and barely one-fourth of that of our grandparents. 

But this gratifying improvement goes deeper, and is 
even more significant than this. It is, of course, only 
natural to expect that our vigorous fight against the 
spread of the infection of the disease would give us 
definite results. But the interesting feature of the situa- 
tion is that this diminution in England and in Germany, 
for instance, began not merely twenty, but thirty, forty, 
even fifty years ago two decades before we even 
knew that tuberculosis was an infectious disease with 
a contagion that could be fought. 

In the case of England, for instance, we have the, 
at first sight, anomalous and even improbable fact that 


the rate of decline in the death-rate from tuberculosis 
for the twenty years preceding the discovery of Koch's 
bacillus was almost as great as it has been in the twenty 
years since. In other words, the general tendency, born 
of civilization, toward sanitary reform, better housing, 
better drainage, higher wages and consequently more 
abundant food, rigid inspection of food materials, fac- 
tory laws, etc., is of itself fighting against and diminish- 
ing the prevalence of the "great white plague" by im- 
proving the resisting power and building up the health 
of the individual. Civilization is curing its own ills. 

It must be remembered that vital statistics, showing 
the decrease of a given disease within the past forty or 
fifty years, probably represent not merely a real de- 
crease of the amount indicated by the figures but an 
even greater one in fact ; because each succeeding dec- 
ade, as our knowledge of disease and the perfection of 
our statistical machinery improves and increases, is 
sure to show a prompter recognition and a more thor- 
ough and complete reporting of all cases of the disease 
occurring. Statistics, for instance, showing a moderate 
apparent rate of increase of a disease within the last 
thirty years are looked upon by statisticians as really 
indicating that it is at a standstill. It is almost certain 
that at least from ten to twenty per cent more of the 
cases actually occurring will be recognized during life 
and reported after death than was possible with our 
more limited knowledge and less effective methods of 
registration thirty years ago. So we need not hesitate to 
encourage ourselves to renewed effort by the reflection 
that we are enlisted in a winning campaign, one in 


which the battle-line is already making steady and even 
rapid progress, and which can have only one termina- 
tion so long as we retain our courage and our common- 

This decline of the tuberculosis death-rate is, of 
course, only a part of the general improvement of phy- 
sique which is taking place under civilization. If we 
could only get out from under the influence of the 
"good old times" obsession and open our eyes to see 
what is going on about us ! There is nothing mysteri- 
ous about it. The soundest of physical grounds for 
improving health can be seen on every hand. We point 
with horror, and rightly, to the slum tenement house, 
but forget that it is a more sanitary human habita- 
tion than even the houses of the nobility in the Eliza- 
bethan age. We become almost hysterical over the 
prospect that the very fibre of the race is to be rotted by 
the adulteration of our food-supply, by oleomargarine 
in the butter, by boric acid in our canned meats, by 
glucose in our sugar, and aniline dyes in our candies, 
but forget that all these things represent extravagant 
luxuries unheard of upon the tables of any but the 
nobility until within the past two hundred, and in 
some cases, one hundred, years. Up to three hundred 
years ago even the most highly civilized countries of 
Europe were subject to periodic attacks of famine; 
our armies and navies were swept and decimated with 
scurvy, from bad and rotten food-supplies; almost 
every winter saw epidemics breaking out from the 
use of half-putrid salted and cured foods ; only forty 
years ago, a careful investigation of one of our most 


conservative sociologists led him to the conclusion 
that in Great Britain thirty per cent of the population 
never in all their lives had quite as much as they could 
eat, and for five months out of the year were never 
comfortably warm. The invention of steam, with its 
swift and cheap transportation of food-supplies, put- 
ting every part of the earth under tribute for our tables, 
meat every day instead of once a week for the work- 
ingman, and the introduction of sugar in cheap and 
abundant form, with the development of the dietary 
in fruits and cereals which this has made possible, have 
done more to improve the resisting power and build 
up the physique of the mass of the population in our 
civilized communities, than ten centuries of congestion 
and nerve-worry could do 'to break it down. 

We shake our heads, and prate fatuously that " there 
were giants in those days," ignorant of the thoroughly 
attested fact, that the average stature of the European 
races has increased some four inches since the days 
of the Crusaders, as shown by the fact that the common 
British soldier of to-day Mr. Kipling'-s renowned 
"Tommy Atkins," who is looked upon by the classes 
above him in the social scale as a short, undersized 
sort of person can neither fit his chest and shoulders 
into their armor, get his hands comfortably on the hilts 
of their famous two-handed swords, nor even lie down 
in their coffins. 

We are at last coming to acknowledge with our lips, 
although we scarcely dare yet to believe it in our heart 
of hearts, that not merely the death-rate from tuber- 
culosis, but the general death-rate from all causes in 


civilized communities, is steadily and constantly de- 
clining ; that the average longevity has increased nearly 
ten years within the memory of most of us, chiefly by 
the enormous reduction in the mortality from infant 
diseases ; and that, though the number of individuals 
in the community who attain a great or notable age is 
possibly not increasing, the percentage of those who 
live out their full, active life, play their man's or wo- 
man's part in the world, and leave a group of properly 
fed, vigorous, well-trained, and educated children be- 
hind them to carry on the work of the race, is far 
greater than ever before. Even in our much-denounced 
industrial conditions, made possible by the discovery of 
steam with its machinery and transportation, the gain 
has far exceeded the loss. While machinery has made 
the laborer's task more monotonous and more confin- 
ing, the net result has been that it has shortened his 
hours and increased his efficiency. 

Even more important, it has increased his intelli- 
gence by demanding and furnishing a premium for 
higher degrees of it. Naturally, one of the first uses 
which he has made of his increased intelligence has 
been to demand better wages and to combine for the 
enforcement of his demands. The premium placed 
upon intelligence has led both the broader-minded, 
more progressive, and more humane among employers, 
and the more intelligent among employees, to recog- 
nize the commercial value of health, and of sanitary 
surroundings, comfort, and healthy recreations, as a 
means of promoting this. The combined results of 
these forces are seen in the incontestable, living fact 


that the death-rate from tuberculosis among intelligent 
artisans and in well-regulated factory suburbs is al- 
ready below that of many classes of outdoor and even 
farm laborers, whose day is from twelve to fourteen 
hours, and whose children are worked, and often over- 
worked, from the time that they can fairly walk alone, 
with as disastrous and stunting results as can be found 
in any mine or factory. Child-labor is one of the oldest 
of our racial evils, instead of, as we often imagine, the 

All over the civilized world to-day the average gen- 
eral death-rate of each city, slums included, is now be- 
low that of many rural districts in the same country. 
If I were to be asked to name the one factor which had 
done more than any other to check the spread and 
diminish the death-rate from tuberculosis I should un- 
hesitatingly say, the marked increase of wages among 
the great producing masses of the country, with the con- 
sequent increased abundance of food, better houses, 
better sanitary surroundings, and last, but not least, 
shorter hours of labor. 

Underfeeding and overwork are responsible for more 
deaths from tuberculosis than any other ten factors. Rest 
and abundant feeding are the only known means for 
its cure. 

This is one of the reasons why the medical profes- 
sion has abandoned all thought of endeavoring to fight 
the disease single-handed, and is striving and straining 
every nerve to enlist the whole community in the fight. 
Its burden rests, not upon the unfortunate individual 
who has become tuberculous, but upon the community 


which, by its ignorance, its selfishness, and its greed, 
has done much to make him so. What civilization has 
caused it is under the most solemn obligation to cure. 

One more brigade of irregular troops on the ex- 
treme left remains to be briefly reviewed, and that is 
those forces resulting from the successive exposure of 
generations to the physical influences of civilization, 
including the infectious diseases. For years we never 
dreamed of even attempting to raise any levies among 
these border tribes of more than doubtful loyalty. 
Indeed, they were supposed to be our open enemies. 

When we first attempted to take a world-view of 
tuberculosis, the first great fact that stood out plainly 
was that it was emphatically a disease of the walled 
town and the city ; that the savage and the nomad bar- 
barian were practically free from it ; that range cattle 
and barnyard fowls seldom fell victims to it, while their 
housed and confined cousins in the dairy barn and the 
breeding-pens suffered frightfully. It was one of our 
commonplace sayings that we must " get back to na- 
ture," get away from the walled city into the open 
country, revert from the conditions of civilization in -a 
considerable degree to those of barbarism, in order to 
escape. While, as for heredity, its influence was al- 
most dead against us. How could a race be exposed 
to a disease like tuberculosis, generation after genera- 
tion, without having its vital resistance impaired ? 

But a marked and cheering change has come over 
our attitude to this wing of the battle of life. So far 
from regarding it as in any sense necessary to revert 


to barbarism, still less to savagery, for either the pre- 
vention or the cure of disease, we have discovered by 
the most convincing, practical experience, that we 
can, in the first place, with the assistance of the loco- 
motive and trolley, combined with modern building 
skill and sanitary knowledge, put even our city-dwellers 
under conditions, in both home and workshop, which 
will render them far less likely to contract tubercu- 
losis than if they were in a peasant's cottage or the 
average farmhouse or merchant's house of a hundred 
years ago, to say nothing of the cave, the dugout, or 
the hut of the savage. 

In the second place, instead of simply "going back 
to nature " and living in brush-shelters on what we 
can catch or shoot, it takes all the resources of civiliza- 
tion to place our open-air patients in the ideal condi- 
tions for their recovery. Let any consumptive be reck- 
less enough to "go back to nature," unencircled by 
the strong arm of civilized intelligence and power, and 
unprotected by her sanitary shield, and nature will 
kill him three times out of five. There could not be 
a more dangerous delusion than the all-too-common 
one that all that is necessary for the cure of con- 
sumption is to turn the victim loose among the elements, 
even in the mildest and most favorable of climates. 

He must be fed upon the most abundant and nu- 
tritious of foods, even the simplest being milk of a 
richness which is given by no kind of wild cattle, and 
which, indeed, only the most carefully bred and highly 
civilized strains of domestic cattle are capable of pro- 
ducing ; eggs such as are laid by no wild bird or by 


any but the most highly specialized of domestic poul- 
try at the season of the year when they are most re- 
quired ; steaks and chops, hams and sides of bacon, 
sugar and fruits and nuts, which simply are not pro- 
duced anywhere outside of civilization, and often only 
in the most intelligent and progressive sections of 
civilized communities. 

Put him upon even the average diet of many people 
in this progressive and highly civilized United States 
the year round, with its thin milk, its pulpy, half- 
sour butter, its tough meat, its half-rancid pickled 
pork, its short three months of really fresh vegetables 
and good fruit, and six months of eternal cabbage, po- 
tatoes, dried apples, and prunes, and he will fail to 
build up the vigor necessary to fight the disease, even 
in the purest and best of air. 

The saddest and most pitiful tragedies which the 
consumptive health-resort physician can relate are 
those of wretched sufferers, even in a comparatively 
early stage of the disease, whose misguided but 
well-meaning friends have raised money enough to 
pay their fare out to Colorado, California, Arizona, or 
New Mexico, and expect them to get work on a ranch, 
so as to earn their living and take the open-air treat- 
ment at the same time. 

Three things are absolutely necessary for a reason- 
able prospect of cure of consumption. One is, abun- 
dance of fresh air, day and night. Another, abundance 
of the best quality of food. And the third, absolute 
indeed, enforced rest during the period of fever. 
Let any one of these be lacking, and your patient will 


die just as certainly as if all three were. Not one in five 
of those who go out to climates with even a high repu- 
tation as health-resorts expecting to earn their own 
living or to "rough it" in shacks or tents on three or 
four dollars a week, doing their own cooking and 
taking care of themselves recovers. They have a 
four- to-one chance of recovery in any climate in which 
they can obtain these three simple requisites, and a 
four-to-one chance of dying in any climate in which 
any one of these is lacking. 

Instead of nature being able to cure the consump- 
tive unaided, as a matter of fact she has neither the 
ability nor the inclination to do anything of the sort. 
There is no class of patients whose recovery depends 
more absolutely upon a most careful and intelligent 
study and regulation of their diet, of every detail of 
their life throughout the entire twenty-four hours, and 
of the most careful adjustment of air, food, heat, cold, 
clothing, exercise, recreation, by the combined forces 
of sanitarian, nurse, and physician. So that, instead of 
feeling that only by reverting to savagery can consump- 
tion be prevented, we have no hesitation in saying that 
it is only under civilization, and civilization of the highest 
type, that we have any reasonable prospect of cure. 

Finally, we are getting over our misgivings as to the 
intentions of the hereditary brigade. It is certainly not 
our enemy, and may probably turn out to be one of our 
best friends. 

Our first sidelight on this question came in rather a 
surprising manner. It was taken for granted, almost 
as axiomatic, that if the conditions of savage life were 


such as to discourage, if not prevent, tuberculosis, 
certainly, then, the race which had been exposed to 
these conditions for countless generations would have 
a high degree of resisting power to the disease. But 
what an awakening was in store for us ! No sooner did 
the army surgeon and medical missionary settle down 
in the wake of that extraordinary world-movement of 
Teutonic unrest, which has resulted in the colonization 
of half the globe within the past two or three hundred 
years, than it was discovered that, although the hunt- 
ing or nomad savage had not developed tuberculosis, 
and the disease was emphatically born of civilization, 
yet the moment that these healthy and vigorous chil- 
dren of nature were exposed to its infection, instead of 
showing the high degree of resisting power that might 
be expected, they died before it like sheep. 

From all over the world from the Indians of our 
Western plains, the negroes of our Southern States, the 
islanders of Polynesia, New Zealand, Hawaii, Samoa 
came reports of tribes practically wiped out of exist- 
ence by the "White Plague" of civilization. To-day 
the death-rate from tuberculosis among our Indian 
wards is from three to six times that of the surrounding 
white populations. The negro population of the South- 
ern States has nearly three times the death-rate of the 
white populations of the same states. Instead of cen- 
turies of civilization having made us more susceptible 
to the disease than those savages who probably most 
nearly parallel our ancestral conditions of a thousand 
to fifteen hundred years ago, we seem to have ac- 
quired irom three to five times their resisting power 


against it. Not only this, but those races among us 
which have been continuous city-dwellers for a score 
of generations past have acquired a still higher degree 
of immunity. 

In every civilized land the percentage of deaths from 
tuberculosis among the Jews, who, from racial and reli- 
gious prejudices, have been prisoners of the Ghetto foi 
centuries, is about half to one-third that of their Ge^ 
tile neighbors. In certain blocks of the congested dis- 
tricts of New York and Chicago, for instance, the Jew- 
ish population shows a death-rate of only one hundred 
and sixty-three per hundred thousand living, while 
the Gentile inhabitants of similar blocks show the 
appalling rate of five hundred and sixty-five. Similarly, 
by a strange apparent paradox, the highest mortality 
from tuberculosis in the United States is not in those 
states having the greatest urban population, but, on 
the contrary, in those having the largest rural popula- 

The ten highest state tuberculosis death-rates con- 
tain the names of Tennessee, Kentucky, West Virginia, 
Virginia, and South Carolina, while New York, Penn- 
sylvania, and Massachusetts are among the lowest. 

The subject is far too wide and complicated to admit 
of any detailed discussion here. But, explain it as we 
may, the consoling fact remains that civilized races, 
including slum-dwellers, have a distinctly lower death- 
rate from tuberculosis than have savage tribes which 
are exposed to it even under most favorable climatic 
and hygienic conditions; that those races which have 
survived longest in city and even slum surroundings 


have a lower death-rate than the rest of the community 
under those conditions ; and that certain of our urban 
populations have lower death-rates than many of our 
rural ones. 

As for the immediate effect of heredity in the produc- 
tion of the disease, the general consensus of opinion 
among thoughtful physicians and sanitarians now is 
that direct infection is at least five times as frequent a 
factor as is heredity; that at least eight-tenths of the 
cases occurring in the children of tuberculous parents 
are probably due to the direct communication of the 
disease, and that if the spread of the infection could 
be prevented, the element of heredity could be prac- 
tically disregarded. 

We are inclined to regard even the well-marked 
tendency of tuberculosis to attack a considerable num- 
ber of the members of a given family to be due largely, 
in the first place, to direct infection; secondly, to the 
fact that that family were all submitted to the same 
unfavorable environment in the matter of food, of 
housing, of overwork, or of the New England con- 
science, with its deadly belief that " Satan finds some 
mischief still for idle hands to do." 

Upon direct pathological grounds nothing is more 
definitely proven than that the actual inheritance of 
tuberculosis, in the sense of its transmission from a 
consumptive mother to the unborn child, is one of the 
rarest of occurrences. On the other hand, the feeling 
is general that, inasmuch as probably four-fifths of us 
are repeatedly exposed to the infection of tuberculosis 
and throw it off without developing a systemic attack 


of the disease, the development of a generalized infec- 
tion, such as we term consumption, is in itself a sign 
of a resisting power below the average. Should such 
an individual as this become a parent, the strong prob- 
ability is that his children unless, as fortunately 
often happens, their other parent should be as far above 
the average of vigor and resisting power would not 
be likely to inherit more vigor than that possessed by 
their ancestry. So that upon a priori grounds we should 
expect to find that the children born of tuberculous 
parents would be more susceptible to the infection 
to which they are so sure to be exposed than the aver- 
age of the race. So that the marriage of consumptives 
should, unquestionably, upon racial grounds, be dis- 
couraged except after they have made a complete re- 
covery and remained well at least five years. 

To sum up: while the earlier steps of civilization 
unquestionably provide that environment which is 
necessary for the development of tuberculosis, the later 
stages, with their greatly increased power over the 
forces of nature, their higher intelligence and their 
broader humanity, not merely have it in their power to 
destroy it, but are already well on the way to do so. 



NOT only have most diseases a living cause, and 
a consequent natural history and course, but they 
have a special method of attack, which looks almost 
like a preference. It seems little wonder that the terror- 
stricken imagination of our Stone Age ancestors should 
have personified them as demons, " attacking" or leap- 
ing upon their victims and "seizing" them with ma- 
levolent delight. The concrete comparison was ready 
to their hand in the attack of fierce beasts of prey; 
and as the tiger leaps for the head to break the 
neck with one stroke of his paw, the wildcat flies at the 
face, the wolf springs for the slack of the flank or the 
hamstring, so these different disease demons appear 
each to have its favorite point of attack : smallpox, the 
skin ; cholera, the bowels ; the Black Death, the arm- 
pits and the groin ; and pneumonia, the lung. 

There are probably few diseases which are so clearly 
recognized by every one and about which popular 
impressions are in the main so clear-cut and so correct 
as pneumonia. The stabbing pain in the chest, the 
cough, the rusty or blood-stained expectoration, the 
rapid breathing, all stamp it unmistakably as a disease 
of the lung. Its furious onset with a teeth-chattering 
chill, followed by a high fever and flushed face, and its 


rapid course toward recovery or death, mark it off 
sharply from all other lung infections. 

Its popular names of " lung fever," " lung plague," 
" congestion of the lungs," are as graphic and distinc- 
tive as anything that medical science has invented. In 
fact, our most universally accepted term for it, pneu- 
monia, is merely the Greek equivalent of the first of 

It is remarkable how many of our disease-enemies 
appear to have a preference for the lung as a point of 
attack. In the language of Old Man Means in "The 
Hoosier Schoolmaster," the lung is " their fav'rit holt." 
Our deadliest diseases are lung diseases, headed by con-* 
sumption, seconded by pneumonia, and followed by 
bronchitis, asthma, etc. ; together, they manage to ac- 
count for one-fourth to -one-third of all the deaths that 
occur in a community, young or old. No other great 
organ or system of the body is responsible for more 
than half such a mortality. Now this bad eminence has 
long been a puzzle, since, foul as is the air or irritating 
as is the gas or dust that we may breathe into our lungs, 
they cannot compare for a moment with the awful con- 
coctions in the shape of food which are loaded into our 
stomachs. Even from the point of view of infections, 
food is at least as likely to be contaminated with dis- 
ease-germs as air is. Yet there is no disease or com- 
bination of diseases of the whole food canal which has 
half the mortality of consumption alone, in civilized 
communities, while in the Orient the pneumonic form 
of the plague is a greater scourge than cholera. 

It has even been suggested that there may possibly 


be a historic or ancestral reason for this weakness to 
attack, and one dating clear back to the days of the 
mud-fish. It is pointed out that the lung is the last of 
our great organs to develop, inasmuch as over half of 
our family tree is under water. When our mud-loving 
ancestor, the lung-fish (who was probably "one of 
three brothers" who came over in the Mayflower 
the records have not been kept) began to crawl out 
on the tide-flats, he had every organ that he needed for 
land-life in excellent working condition and a fair de- 
gree of complexity: brain, stomach, heart, liver, kid- 
neys; but he had to manufacture a lung, which he 
proceeded to do out of an old swim-bladder. This, 
of course, was several years ago. But the lung has not 
quite caught up yet. The two or three million year lead 
of the other organs was too much to be overcome all at 
once. So carelessly and hastily was this impromptu 
lung rigged up that it was allowed to open from the 
front of the gullet or oesophagus, instead of the back, 
while the upper part of the mouth was cut off for its 
intake tube, as we have already seen in considering 
adenoids, thus making every mouthful swallowed cut 
right across the air-passages, which had to be provided 
with a special valve-trap (the epiglottis) to prevent food 
from falling into the lungs. 

So, whenever you choke at table, you have a right 
to call down a benediction upon the soul of your long 
departed ancestor, the lung-fish. However applicable or 
remote we may regard " the bearin's of this observa- 
tion," the practical and most undesirable fact confronts 
us to-day that this crossing and mutual interference of 


the air and the food-passages is a fertile cause of pneu- 
monia, inasmuch as the germs of this disease have their 
habitat in the mouth, and are from that lurking-place 
probably inhaled into the lung, as is also the case with 
the germs of several milder bronchitic and catarrhal 

It may be also pointed out that, history apart, our 
lung-cells at the present day are at another disadvan- 
tage as compared with all the other cells of the body, 
except those of the skin ; and that is, that they are in 
constant contact with air, instead of being submerged 
in water. Ninety-five per cent of our body-cells are 
still aquatic in their habits, and marine at that, and can 
live only saturated with, and bathed in, warm saline 
solution. Dry them, or even half-dry them, and they 
die. Even the pavement-cells coating our skin sur- 
faces are practically dead before they reach the air, 
and are shed off daily in showers. 

We speak of ourselves as " land animals," but it is 
only our lungs that are really so. All the rest of the 
body is still made up of sea creatures. It is little wonder 
that our lungs should pay the heaviest penalty of our 
change from the warm and equable sea water to the 
gusty and changeable air. 

Even if we have set down the lung as a point of 
the least resistance in the body, we have by no means 
thereby explained its diseases. Our point of view has 
distinctly shifted in this respect within recent years. 
Twenty years ago pathologists were practically content 
with tracing a case of illness or death to an inflamma- 
tion or disease of some particular organ, like the heart, 


the kidney, the lung, or the stomach. Now, however, 
we are coming to see that not only may the causation 
of this heart disease, kidney disease, lung disease, have 
lain somewhere entirely outside of the heart, kidney, 
or lung, but that, as a rule, the entire body is affected 
by the disease, which simply expresses itself more 
violently, focuses, as it were, in this particular organ. 
In other words, diseases of definite organs are most 
commonly the local expressions of general diseases or 
infections; and this local aggravation of the disease 
would never have occurred if the general resisting 
power and vigor of the entire body had not been de- 
pressed below par. So that even in guarding against or 
curing a disease of a particular organ it is necessary to 
consider and to treat the whole body. 

Nowhere is this new attitude better illustrated than in 
pneumonia. Frank and unquestioned infection as it is, 
wreaking two-thirds of its visible damage in the lung 
itself, the liability to its occurrence and the outlook for 
its cure depend almost wholly upon the general vigor 
and rallying power of the entire body. It is perfectly 
idle to endeavor to avoid it by measures directed 
toward the protection of the lung or of the air-passages, 
and equally futile to attempt to arrest its course by 
treatment directed to the lung, or even the chest. The 
best place to wear a chest-protector is on the soles of 
the feet, and poulticing the chest for pneumonia is 
about as effective as shampooing the scalp for brain- 

This clears the ground of a good many ancient mis- 
conceptions; for instance, that the chief cause of 


pneumonia is direct exposure to cold or a wetting, or 
the inhalation of raw, cold air. Few beliefs were more 
firmly fixed in the popular mind and, for the matter of 
that, in the medical up to fifteen or twenty years ago. 
It has found its way into literature ; and the hero of the 
shipwreck in an icy gale or of weeks of wandering in 
the Frozen North, who must be offered up for artistic 
reasons as a sacrifice to the plot, invariably dies a vic- 
tim of pneumonia, from his "frightful exposure," just 
as the victim of disappointed love dies of "a broken 
heart," or the man who sees the ambitions of years 
come crashing about his ears, or the woman who has 
lost all that makes life worth living, invariably develops 
"brain fever." 

There is a physical basis for all of these standard 
catastrophes, but it is much slenderer than is usually 
supposed. For instance, almost every one can tell you 
how friends of theirs have " brought on congestion of 
the lungs," or pneumonia, by going without an over- 
coat on a winter day, or breaking through the ice when 
skating, or even by getting their feet wet and not chang- 
ing their stockings; and this single dramatic instance 
has firmly convinced them that the chief cause of 
" lung fever " is a chill or a wetting. Yet when we come 
to tabulate long series of causes, rising into thousands, 
we find that the percentage in which even the patients 
themselves attribute the disease to exposure, or a chill, 
sinks to a surprisingly small amount. For instance, 
in the largest series collected with this point in mind, 
that of Musser and Norris, out of forty-two hundred 
cases only seventeen per cent gave a history of exposure 


and "catching cold"; and the smaller series range 
from ten to fifteen per cent. So that, even in the face of 
the returns, not more than one-fifth of all cases of 
pneumonia can reasonably be attributed to chill. 
And when we further remember that under this head- 
ing of exposure and " catching cold " are included many 
mere coincidences and the chilly sensations attending 
the beginning of those milder infections which we term 
"common colds," it is probable that even this small 
percentage could be reduced one-half. Indeed, most 
cautious investigators of the question have expressed 
themselves to this effect. This harmonizes with a 
number of obstinate facts which have long proved stum- 
bling-blocks in the way of the theory of exposure as a 
cause of pneumonia. One of the classic ones was that, 
during Napoleon's frightful retreat from Moscow in the 
dead of winter, while his wretched soldiers died by 
thousands of frost-bite and starvation, exceedingly little 
pneumonia developed among them. Another was that, 
as we have already seen with colds, instead of being 
commoner and more frequent in the extreme Northern 
climate and on the borders of the Arctic Zone, pneu- 
monia is almost unknown there. Of course, given the 
presence of the germ, prolonged exposure to cold may 
depress the vital powers sufficiently to permit an attack 
to develop. 

Again, the ages at w r hich pneumonia is both most 
common and most deadly, namely, under five and over 
sixty-five, are precisely those at which this feature of ex- 
posure to the weather plays the most insignificant part. 
Last and most conclusive of all, since definite statistics 


have begun to be kept upon a large scale, pneumonia 
has been found to be emphatically a disease of cities, 
instead of country districts. Even under the favorable 
conditions existing in the United States, for instance, 
the death-rate per hundred thousand living, according 
to the last census, was in the cities two hundred and 
thirty-three, and for the country districts one hundred 
and thirty-five, in other words, nearly seventy per 
cent greater in city populations. 

How, then, did the impression become so widely 
spread and so firmly rooted that pneumonia is chiefly 
due to exposure ? Two things, I think, will explain 
most of this. One is, that the disease is most com- 
mon in the winter- time, the other, that like all febrile 
diseases it most frequently begins with sensations of 
chilliness, varying all the way from a light shiver to 
a violent chill, or rigor. The savage, bone-freezing, 
teeth-rattling chill which ushers in an attack of pneu- 
monia is one of the most striking characteristics of the 
disease, and occurs in twenty-five to fifty per cent of all 

Its chief occurrence in the winter-time is an equally 
well-known and undisputed fact, and it has been for 
centuries set down in medical works as one of the dis- 
eases chiefly due to changes in temperature, humidity, 
and directions of the wind. Years of research have 
been expended in order to trace the relations between 
the different factors in the weather and the occurrence 
of pneumonia, and volumes, yes, whole libraries, pub- 
lished, pointing out how each one of these factors, the 
temperature, humidity, direction of wind, barometric 


pressure, and electric tension, is in succession the prin- 
cipal cause of the spread of this plague. Many interest- 
ing coincidences were shown. But one thing always 
puzzled us, and that was, that the heaviest mortality 
usually occurred, not just at the beginning of winter, 
when the shock of the cold would be severest, nor even 
in the months of lowest temperature, like December 
or January, but in the late winter and the early spring. 
Throughout the greater part of the temperate zone 
the death-rate for pneumonia begins to rise in Decem- 
ber, increases in January, goes higher still in Febru- 
ary, reaching its climax in that month or in March. 
April is almost as bad, and the decline often does n't 
fairly set in until May. 

No better illustration could probably be given of the 
danger of drawing conclusions when you are not in pos- 
session of all the facts. One thing was entirely over- 
looked in all this speculation until about twenty years 
ago, that pneumonia was due not simply to the de- 
pressing effects of cold, but to a specific germ, the pneu- 
mococcus of Fraenkel. This threw an entirely new light 
upon our elaborate weather-causation theories. And 
while these still hold the field by weight of authority 
and that mental inertia which we term conservatism, yet 
the more thoughtful physicians and pathologists are 
now coming to regard these factors as chiefly important 
according to the extent to which we are crowded to- 
gether in often badly lighted and ill-ventilated houses 
and rooms, with the windows and doors shut to save 
fuel, thus affording a magnificent hothouse hatching- 
ground for such germs as may be present, and ideal 


facilities for their communication from one victim to 
another. At the same time, by this crowding and the 
cutting off of life and exercise in the open air which 
accompanies it, the resisting power of our bodies is low- 
ered. And when these two processes have had an oppor- 
tunity of progressing side by side for from two to three 
months; when, in other words, the soil has been care-, 
fully prepared, the seed sown, and the moist heat applied 
as in a forcing-house, then we suddenly reap the har- 
vest. In other words, the heavy crop of pneumonia in 
January, February, and March is the logical result of 
the seed-sowing and forcing of the preceding two or 
three months. 

The warmth of summer is even more depressing in its 
immediate effects than the cold of winter, but the heat 
carries with it one blessing, in that it drives us, willy- 
nilly, into the open air, day and night. And on looking 
at statistics we find precisely what might have been ex- 
pected on this theory, that the death-rate for pneu- 
monia is lowest in July and August. 

It might be said in passing that, in spite of our vivid 
dread of sunstroke, of cholera, and of pestilence in hot 
weather, the hot months of the year in temperate cli- 
mates are invariably the months of fewest diseases and 
fewest deaths. Our extraordinary dread of the summer 
heat has but slender rational physical basis. It may 
be but a subconscious after-vibration in our brain cells 
from the simoons, the choleras, and the pestilences of 
our tropical origin as a race. Open air, whether hot, 
cold, wet, dry, windy, or still, is our best friend, and 
house air our deadliest enemy. 


If this view be well founded, then the advance of 
modern civilization would tend to furnish a more and 
more favorable soil for the spread of this disease. This, 
unfortunately, is about the conclusion to which we are 
being most unwillingly driven. Almost every other 
known infectious disease is diminishing, both in fre- 
quency and in fatality, under civilization. Pneumonia 
alone defies our onslaughts. In fact, if statistics are to 
be taken at their surface-value, we are facing the appal- 
ling situation of an apparently marked increase both 
in its prevalence and in its mortality. For a number 
of years past, ever since, in fact, accurate statistics 
began to be kept, pneumonia has been listed as the 
second heaviest cause of death, its only superior being 

About ten years ago it began to be noticed that the 
second competitor in the race of death was overtaking 
its leader, and this ghastly rivalry continued until about 
three years ago pneumonia forged ahead. In some 
great American cities it now occupies the bad eminence 
of the most fatal single disease on the death-lists, 

The situation is, however, far from being as serious 
and alarming as it might appear, simply from this bald 
statement of statistics. First of all, because the forging 
ahead of pneumonia has been due in greater degree 
to the falling behind of tuberculosis than to any actual 
advance on its part. The death-rate of tuberculosis 
within the last thirty years has diminished between 
thirty and forty per cent ; and pneumonia at its worst 
has never yet equaled the old fatality of tuberculosis. 
Furthermore, all who have carefully studied the subject 


are convinced that much of this apparent increase is 
due to more accurate and careful diagnosis. Up to ten 
years or so ago it was generally believed that pneu- 
monia was rare in young children. Now, however, 
that we make the diagnosis with a microscope, we dis- 
cover that a large percentage of the cases of capillary 
bronchitis, broncho-pneumonia, and acute congestion 
of the lung in children are due to the presence of the 
pneumococcus. Similarly, at the other end of the line, 
deaths that were put down to bronchitis, asthma, heart 
failure, yes, even to old age, have now been shown on 
bacteriological examination to be due to this ubiqui- 
tous imp of malevolence; so that, on the whole, all 
that we are probably justified in saying is that pneu- 
monia is not decreasing under civilization. This is 
not to be wondered at, inasmuch as the inevitable 
crowding and congestion which accompanies civiliza- 
tion, especially in its derivative sense of " citification," 
tends to foster it in every way, both by multiplying the 
opportunities for infection and lowering the resisting 
power of the crowded masses. 

Moreover, it was only in the last ten years, yes, 
within the last five years, that we fairly grasped the 
real method and nature of the spread of the disease, 
and recognized the means that must be adopted against 
it. And as all of these factors are matters which are 
not only absolutely within our own control, but are 
included in that programme of general betterment of 
human comfort and vigor to which the truest intelli- 
gence and philanthropy of the nation are now being 
directed, the outlook for the future, instead of being 
gloomy, is distinctly encouraging. 


Our chief difficulty in discovering the cause of pneu- 
monia lay in the swarm of applicants for the honor. 
Almost every self-respecting bacteriologist seemed to 
think it his duty to discover at least one, and the abun- 
dance and variety of germs constantly or accidentally 
present in the human saliva made it so difficult posi- 
tively to isolate the real criminal that, although it was 
identified and described as long ago as 1884 by Fraen- 
kel, the validity of its claim was not generally recog- 
nized and established until nearly ten years later. 

It is a tiny, inoffensive-looking little organism, of an 
oval or lance-head shape, which, after masquerading 
under as many aliases as a confidence man, has finally 
come to be called the pneumococcus, for short, or 
"lung germ." Though by those who are more precise 
it is still known as the Diplococcus pneumonias or 
Diplococcus lanceolatus, from its faculty of usually ap- 
pearing in pairs, and from its lance-like shape. Its 
conduct abounds in "ways that are dark and tricks 
that are vain," whose elucidation throws a flood of 
light upon a number of interesting problems in the 
spread of disease. 

First of all, it literally fulfills the prognostic of Scrip- 
ture, that " a man's foes shall be they of his own house- 
hold," for its chosen abiding place and normal habitat 
is no less intimate a place than the human mouth. Out- 
side of this warm and sheltering fold it perishes quickly, 
as cold, sunlight, and dryness are alike fatal to it. 

We could hardly believe the evidence of our senses 
when studies of the saliva of perfectly healthy indi- 
viduals showed this deadly little bacillus to be present 


in considerable numbers in from fifteen to forty-five 
per cent of the cases examined. Why, then, does not 
every one develop pneumonia? The answer to this 
strikes the keynote of our modern knowledge of infec- 
tious disease, namely, that while an invading germ 
is necessary, a certain breaking down of the body de- 
fenses and a lowering of the vital resistance are equally 
necessary. These invaders lie in wait at the very gates 
of the citadel, below the muzzles of our guns, as it were, 
waiting for some slackening of discipline or of watch- 
fulness to rush in and put the fortress to sack. Nowhere 
is this more strikingly true than in pneumonia. It is 
emphatically a disease where, in the language of the 
brilliant pathologist-philosopher Moxon, "While it is 
most important to know what kind of a disease the 
patient has got, it is even more important to know 
what kind of a patient the disease has got." 

The death-rate in pneumonia is an almost mathemat- 
ically accurate deduction from the age, vigor, and nutri- 
tion of the patient attacked. No other disease has such 
a brutal and inveterate habit of killing the weaklings. 
The half-stifled baby in the tenement, the underfed, 
overworked laboring man, the old man with rigid ar- 
teries and stiffening muscles or waning life vigor, the 
chronic sufferer from malnutrition, alcoholism, Bright's 
disease, heart disease these are its chosen victims. 

Another interesting feature about the pneumococcus 
is its vitality outside of the body. If the saliva in which 
it is contained be kept moist, and not exposed to the 
direct sunlight and in a fairly warm place, it may sur- 
vive as long as two weeks. If dried, but kept in the 


dark, it will survive four hours. If exposed to sunlight, 
or even diffuse daylight, it dies within an hour. In 
other words, under the conditions of dampness and 
darkness which often prevail in crowded tenements 
it may remain alive and malignant for weeks ; in de- 
cently lighted and ventilated rooms, less than two 
hours. This explains why, in private practice and 
under civilized conditions, epidemics of this admittedly 
infectious disease are rare ; while in jails, overcrowded 
barracks, prison ships, and winter camps of armies in 
the field they are by no means uncommon. This is 
vividly supported by the fact brought out in our later 
investigations of the sputum of slum-dwellers, carried 
out by city boards of health, that the percentage of 
individuals harboring the pneumococcus steadily in- 
creases all through the winter months, from ten per 
cent in December to forty-five, fifty, and even sixty 
per cent in February and March. The old proverb, 
"When want comes in at the door, Love flies out at 
the window," might be revised to read, " When sunlight 
comes in at the window the pneumococcus flies * up 
the flue.'" 

Authorities are still divided as to the meaning and 
even the precise frequency of the occurrence of the 
pneumococcus in the healthy human mouth. Some 
hold that its presence is due to recent infection which 
has either been unable to gain entrance to the system 
or is preparing its attack; others, that it is a survival 
from some previous mild attack of the disease, and the 
body tissues having acquired immunity against it, 
it remains in them as a harmless parasite, as is now 


well known to be the case with the germs of several 
of our infectious diseases for instance, typhoid - 
for months and even years afterward. Others hold the 
highly suggestive view that it is a normal inhabitant 
of the healthy mouth, which can become injurious 
to the body, or pathogenic, only under certain depressed 
or disturbed conditions of the latter. In defense of this 
last it may be pointed out that dental bacteriologists 
have now already isolated and described some thirty 
different forms of organisms which inhabit the mouth 
and teeth ; and the pneumococcus may well be one of 
these. Further, that a number of our most dangerous 
disease germs, like the typhoid bacillus, the bacillus of 
tuberculosis, and the bacillus of diphtheria, have almost 
perfect "doubles," law-abiding relatives, so to speak, 
among the germs that normally inhabit our throats, 
our intestines, or our immediate surroundings. The 
ultimate foundation question of the science of bacteri- 
ology is, How did the disease germs become disease 
germs ? But the question is still unanswered. 

However, fortunately, here, as in other human 
affairs, imperfect as our knowledge is, it is sufficient 
to serve as a guide for practical conduct. Widely pre- 
sent as the pneumococcus is, we know well that it is 
powerless for harm except in unhealthful surroundings. 
There is another interesting feature of its life history 
which is of practical importance, and that is, like many 
other bacilli it is increased in virulence and infectious- 
ness by passing through the body of a patient. Flushed 
with victory over a weakened subject, it acquires cour- 
age to attack a stronger. This is the reason why, 


in those comparatively infrequent instances in which 
pneumonia runs through a family, it is the strongest 
and most vigorous members of the family who are the 
last to be attacked. It also explains one of the para- 
doxes of this disease, that, while emphatically a disease 
of overcrowding and foul air, and attacking chiefly 
weakened individuals, it is a veritable scourge of 
camps, whether mining or military. When once three 
or four cases of pneumonia have occurred in a mining 
camp, even though this consist almost exclusively of 
vigorous men, most of them in the prime of life, it 
acquires a virulence like that of a pestilence, so that, 
while ordinarily not more than fifteen to twenty per 
cent of those attacked die, death-rates of forty, fifty, 
and even seventy per cent are by no means uncommon 
in mining camps. The fury and swiftness of this 
"miners' pneumonia" is equally incredible. Strong, 
vigorous men are taken with a chill while working in 
their sluicing ditches, are delirious before night, and 
die within forty-eight hours. So widely known are these 
facts, and so dreaded is the disease throughout the Far 
West and in mountain regions generally, that there is 
a widespread belief that pneumonia at high altitudes 
is particularly deadly. 

I had occasion to interest myself in this question 
some years ago, and by writing to colleagues practicing 
at high elevations and collecting reports from the liter- 
ature, especially of the surgeons of army posts in 
mountain regions, was somewhat surprised to find that 
the mortality of all cases occurring above five thousand 
feet elevation was almost identical with that of a similar 


class of the population at sea-level. It is only when a 
sufficient number of cases occur in succession to raise 
the virulence of the pneumococcus in this curious man- 
ner that an epidemic with high fatality develops. 

That this increase in virulence in the organism does 
occur was clearly demonstrated by a bacteriologist 
friend of mine, who succeeded in securing some of 
the sputum from a fatal case in the famous Tonopah 
epidemic of some years ago, an epidemic so fatal that 
it was locally known as the "Black Death." Upon 
injecting cultures from this sputum into guinea-pigs, 
the latter died in one-quarter of the time that it usually 
took them to succumbto a similar dose of an ordinary 
culture of the pneumococcus. 

It is therefore evident that just as "no chain is 
stronger than its weakest link," so in the broad sense 
no community is stronger than its weakest group of 
individuals, and pneumonia, like other epidemics, 
may be well described as the vengeance which the 
"submerged tenth" may wreak from time to time 
upon their more fortunate brethren. 

Now that we know that under decent and civilized 
conditions of light and ventilation the pneumococcus 
will live but an hour to an hour and a half, this re- 
duces the risk of direct infection under these conditions 
to a minimum. It is obvious that the principal factors 
in the control of the disease are those which tend to 
build up the vigor and resisting power of all possible 
victims. The more broadly we study the disease the 
more clearly do the data point in this direction. 

First of all, is the vivid and striking contrast between 


hospital statistics and those gathered from private 
practice. While many individuals of a fair wage- 
earner's income and good bodily vigor are treated in 
our hospitals, yet the vast majority of hospital patients 
are technically known as the "hospital classes," apt 
to be both underfed, overworked, and overcrowded. 
On the other hand, while a great many both of the 
very poor and even of the destitute are treated in private 
practice, yet the majority of such cases who feel " able 
to afford a doctor," as they say, are among the com- 
paratively vigorous, well-fed, and well-housed section 
of the community. And the difference between the 
death-rate of the two classes in pneumonia is most 
significant. In private practice, while epidemics differ 
in virulence, the rate ranges all the way from five per 
cent to fifteen per cent, the average being not much in 
excess of ten per cent, occasionally falling as low as 
three per cent. In the hospital reports on the contrary 
the death-rate begins at twenty per cent and climbs to 
thirty, forty, and forty-five per cent. It is only fair to 
say, of course, that hospital statistics probably include 
a larger percentage of more serious cases, the milder 
ones being taken care of at home, or not presenting 
themselves for treatment at all. But even when this 
allowance has been made, the contrast is convincing. 
A similar influence is exercised by age. Although 
pneumonia is common at all ages, its heaviest death- 
rate falls at the two extremes, under six years of age 
and over sixty, with a strong preponderance in the 
latter. Under five years of age, the mortality may reach 
twenty to thirty per cent ; from five to twenty-five, not 


more than four to five per cent ; from twenty-five to 
thirty-five, from fifteen to twenty per cent ; and so on, 
increasing gradually with every decade until by sixty 
years of age the mortality has reached fifty per cent, 
and from sixty to seventy-five may be expressed in 
terms of the age of the patient. One consoling feature, 
however, about it is that its mortality is lowest in the 
ages at which it is most frequent, namely, from ten 
to thirty-five years of age. And its frequency dimin- 
ishes even more rapidly than its fatality increases in 
later years. So that while it is much more serious in 
a middle-aged man, he is less liable to develop it than 
a younger one. Where the mortality from pneumonia is 
highest, is in the most densely populated wards, espe- 
cially among negroes and foreigners of the hospital 
class, in individuals who are victims of chronic alco- 
holism, and also among those who are for long periods 
insufficiently nourished. Lastly, it is only within com- 
paratively recent years that we have come clearly to 
recognize the large role which pneumonia plays in 
giving the finishing stroke to chronic diseases and de- 
generative processes. It is, for instance, one of the 
commonest actual causes of death in Bright's dis- 
ease, in diabetes, in lingering forms of tuberculosis, and 
in heart disease; and last of all, in that progressive pro- 
cess of normal degeneration and decay which we term 
" Old Age." It is one of the most frequent and fatal of 
what Flexner described a decade ago as "terminal 
infections." Very few human beings die by a gradual 
process of decay, still less go to pieces all at once, like 
the immortal " One-Hoss Shay." Just as soon as the 


process has progressed far enough to lower the resist- 
ing power below a certain level, some acute infection 
steps in and mercifully ends the scene. This is pecu- 
liarly true of pneumonia in old age. 

To the medical profession to "die of old age" is 
practically equivalent to dying of pneumonia. The 
disease is so mild in its symptoms and so rapid in 
its course that it often utterly escapes recognition as 

The old man complains of a little pain in his chest, 
a failure of appetite, a sense of weakness and dizziness. 
He takes to his bed, within forty-eight hours he be- 
comes unconscious, and within twenty-four more 
he is peacefully breathing his last. After death, two- 
thirds of the lung will be found consolidated. So mild 
and rapid and painless is the process that one phy- 
sician-philosopher actually described pneumonia as 
"the friend of old age.'* 

When once the disease has obtained a foothold in 
the body its course, like one of Napoleon's campaigns, 
is short, sharp, and decisive. Beginning typically with a 
vigorous chill, sometimes so suddenly as to wake the 
patient out of a sound sleep, followed by a stabbing 
pain in the side, cough, high fever, rapid respiration, the 
sputum rusty or orange-colored from leakage of blood 
from the congested lung, within forty-eight hours the 
attacked area of the lung has become congested; in 
forty-eight more, almost solidified by the thick, sticky 
exudate poured out from the blood-vessels, which co- 
agulates and clots in the air cells. So complete is this 
solidification that sections of the attacked lung, instead 


of floating in water as normal lung-tissue will, sink 
promptly. The severe pain usually subsides soon, but 
the fever, rapid respiration, flushed face, with or with- 
out delirium, will continue for from three to seven or 
eight days. Then, as suddenly as the initial attack, 
comes a plunge down of the temperature to normal. 
Pain and restlessness disappear, the respiration drops 
from thirty-five or forty to fifteen or twenty per minute, 
and the disease has practically ended by "crisis." Nat- 
urally, after such a furious onslaught, the patient is apt 
to be greatly weakened. He may have lost twenty or 
thirty pounds in the week of the fever, and from one to 
three weeks more in bed may be necessary for him to 
regain his strength. But the chief risk and danger 
are usually over within a week or ten days at the out- 

Violent and serious as are the changes in the lung, 
it is very seldom that death comes by interference with 
the breathing space. In fact, while regarded as a lung 
disease, we are now coming to recognize that the actual 
cause of death in fatal cases is the overwhelming of the 
heart by the toxins or poisons poured into the circu- 
lation from the affected lung. The mode of treatment 
is, therefore, to support the strength of the patient in 
every way, and measures directed to the affected lung 
are assuming less and less importance in our arsenal 
of remedies. Our attitude is now very similar to that 
in typhoid, to support the strength of the patient by 
judicious and liberal feeding, to reduce the fever and 
tone up his blood-vessels by cool sponging, packing, 
and even bathing; to relieve his pain by the mildest 


possible doses of sedatives, knowing that the disease is 
self-limited, and that in patients in comfortable sur- 
roundings and fair nutrition from eighty to ninety per 
cent will throw off the attack within a week. So com- 
pletely have we abandoned all idea of medicating or 
protecting the lung as such, that in place of over- 
heated rooms, loaded with vapor by means of a steam 
kettle, for its supposed soothing effect upon the in- 
flamed lung, we now throw the windows wide open. 
And some of our more enthusiastic clinicians of wide 
experience are actually introducing the open-air cure, 
which has worked such wonders in tuberculosis, in the 
treatment of pneumonia. In more than one of our New 
York hospitals now, particularly those devoted to the 
care of children, following the brilliant example of 
Dr. William Northrup, wards are established for pneu- 
monia cases out on the roof of the hospital, even when 
the snow is banked up on either side, and the covering 
is a canvas tent. Nurses, physicians, and ward attend- 
ants are clothed in fur coats and gloves, the patients 
are kept muffled up to the ears, with only the face ex- 
posed ; but instead of perishing from exposure, little, 
gasping, struggling tots, whose cases were regarded as 
practically hopeless in the wards below, often fall into 
the sleep that is the turning point toward recovery 
within a few hours after being placed in this winter 
roof -garden. 

In short, our motto may be said to be, "Take 
care of the patient, and the disease will take care of 

Though pneumonia is one of our most serious and 


most fatal of diseases, yet it is one over whose cause, 
spread, and cure we are obtaining greater and greater 
control every day, and which certainly should, within 
the next decade, yield to our attack, as tuberculosis and 
typhoid are already beginning to do. 



WHY should not a disease have a natural history, 
as well as an individual ? At first sight, this 
might appear like a reversion to the old, crude theory of 
disease as a demonic obsession, or invasion by an evil 
spirit, of which traces still remain in such expressions 
as, "She was seized with a convulsion," "He was 
strong enough to throw off the illness," "He was at- 
tacked by a fever," etc. But apart entirely from such 
conceptions, which were perfectly natural in the in- 
fancy of the race, while clearly recognizing that disease 
is simply a perverted state of nutrition or well-being 
in the body of the patient, a disturbance of balance, 
so to say, yet it is equally true that it has a birth, 
an ancestry, a life-course, and a natural termination, 
or death. 

This recognition of the natural causation and devel- 
opment of disease has been one of the greatest tri- 
umphs, not merely of pathology, but of intelligence 
and rationalism. It has done more to diminish that 
dread of the unknown w T hich hangs like a black pall of 
terror over the mind of the savage and the semi-civil- 
ized mind than any other one advance. It contributes 
enormously to our courage, our hopefulness, and our 
power of protection in more ways than one: first of 
all, by revealing to us the external cause of disease, 


usually some careless, dirty, or bad habit on the part 
of an individual or of the community, and thus enabling 
us to limit its spread and even exterminate it ; secondly, 
by assuring us that nearly all diseases, excepting a few 
of the most obstinate and serious, have not only a 
definite beginning, but a definite end, are, in fact, 
if left to themselves, self-limited, either by the exhaus- 
tion and loss of virulence of their cause, or by the 
resisting power of the body. 

All infectious diseases, and many others, tend to 
run a definite course of so many days, or so many 
weeks, within certain limits, and at least ninety per 
cent of them tend to terminate in recovery. It is a most 
serious and fatal disease which has a death-rate of more 
than twenty per cent. Typhoid, pneumonia, diph- 
theria, and yellow fever all fall below this, smallpox 
barely reaches it, and only the bubonic plague, cholera, 
and lockjaw rise habitually above it. The recognition 
of this fact has enormously increased the efficiency 
of the medical profession in dealing with disease, by 
putting us on the track of imitating the methods 
which the body itself uses for destroying, or checking 
the spread of, invading germs and leading us to trust 
nature and try to work with her instead of against her. 
Our antitoxins and anti-serums, which are our bright- 
est hope in therapeutics at present, are simply antidotes 
which are formed in the blood of some healthy, vigor- 
ous animal against the bacillus whose virulence we wish 
to neutralize, such as that of diphtheria or septicemia. 

Diphtheria antitoxin, for instance, the first and best 
known triumph of the new medicine, is the antidotal 


substance formed in the blood of a horse in response 
to a succession of increasing doses of the bacilli of diph- 
theria. Similar antidotal substances are formed in the 
blood in all other non-fatal cases of infectious diseases, 
such as typhoid, pneumonia, blood-poisoning, etc. ; and 
the point at which they have accumulated in sufficient 
amounts to neutralize the poison of the invading germs, 
forms the crisis, or " turn " of the disease. So that when 
we speak of a disease " running its course," we mean 
continuing for such length of time as the body needs to 
produce anti-bodies in sufficient amounts to check it. 

The principal obstacle to the securing of antitoxins 
like that of diphtheria for all our infectious diseases is, 
that their germs form their poison so slowly that it is 
difficult to collect it in sufficient amounts to produce 
a strong concentrated antitoxin in the animal into 
which it is injected. But the overcoming of this diffi- 
culty is probably only a question of time. 

Obviously, if infectious disease be, as we say, " self- 
limited," that is to say, if the body will defeat the in- 
vaders with its own weapons, on an average in nine 
cases out of ten, our wisest course, as physicians, is 
to back up the body in its fight. This we now do in 
every possible way, by careful feeding, by rest, by 
bathing, by an abundance of pure water and fresh air, 
with the gratifying result that we have already reduced 
the death-rate in most fevers, even such as we have 
no antitoxin against, or may not even have discovered 
the causal germ of, to one-half and even three-fourths 
of their former fatality. The recognition of the fact 
that disease has a natural history, a birth, a term of 


natural life and a death, has already turned a hope- 
less fight in the dark into a victorious campaign in 
broad daylight. Huxley's pessimistic saying that 
typhoid was like a fight in the dark between the dis- 
ease and the patient, and the doctor like a man with 
a club striking into the melee, sometimes hitting the 
disease and sometimes the patient, is no longer true 
since the birth of bacteriology. 

Nowhere can the natural history of disease be more 
clearly seen or more advantageously studied than in the 
case of typhoid fever. 

The cause of typhoid is simplicity itself, merely 
drinking the excreta of some one else, "eating dirt," 
in the popular phrase; simple, but of a deadly effec- 
tiveness, and disgracefully common. The demon may 
be exorcised by an incantation of one sentence : Keep 
human excreta out of the drinking water. This sounds 
simple, but it is n't. Eternal vigilance is the price of 
health as well as of liberty. 

We can, however, make our pedigree of typhoid a 
little more precise. It is not merely dirt of human origin 
which is injurious, but dirt of a particular type, 
namely, discharges from a previous case of the disease. 
Just as in the fight against malaria we have not the 
enormous problem of the extermination of all varieties 
of mosquito, but only of one particular genus, and 
only the infected specimens of that, so in typhoid, 
the contamination of water or food which we have to 
guard against is that from previous cases. From one 
point of view, this leaves the problem as wide as 
ever, for, obviously, the only way to insure against 


poisoning of water by typhoid discharges is to shut out 
absolutely all sewage contamination. On the other 
hand, it is of immense advantage in this regard, it 
enables us to fight the enemy at both ends of the line, 
to turn his flank as well as crush his centre. 

While we are protecting our water-supplies against 
sewage, we can, in the meantime, render that sewage 
comparatively harmless by thoroughly disinfecting and 
sterilizing all discharges from every known case of the 
disease. A similar method is used in the fight against 
yellow fever and malaria. Not only are the breeding 
places of the two mosquito criminals broken up, but 
each known case of the disease is carefully screened, so 
as to prevent the insects from becoming infected, and thus 
able to transmit the disease to other human victims. 

It cannot be too emphatically insisted upon that 
every case of typhoid, like every case of yellow fever 
and of malaria, comes from a previous case. It is neither 
healthy nor exhilarating to drink a clear solution of 
sewage, no matter how dilute; but, as a matter of fact, 
it is astonishing how long communities may drink 
sewage-laden water with comparative impunity, so 
long as the sewage contains no typhoid discharges. 
One case of typhoid fever imported into a watershed 
will set a city in a blaze. 

The malevolent Deus in the sewage machina is, of 
course, a germ the Bacillus typhosus of Eberth. The 
astonishing recentness of much of our most important 
knowledge is nowhere better illustrated than in the 
case of typhoid. Although there had been vague de- 
scriptions of a fatal fever, slow and lingering in its 


character and accompanied by prolonged stupor and 
delirium, which was associated with camps and dirty 
cities and famines, from as far back as the age of Caesar, 
the first description clear enough to be recognizable 
was that of Willis, of an epidemic during the English 
civil war in 1643, both Royalist and Roundhead armies 
being seriously crippled by it. Since that time a smoul- 
dering, slowly spreading fever has been pretty con- 
stantly associated with armies in camps, besieged cities, 
filthy jails, and famines, to which accordingly have 
been given the names, familiar in historical literature, 
of "famine fever," "jail fever," and "military fever." 

So slowly, however, did accurate knowledge come, 
that 'it was actually not until 1837 that it was clearly 
and definitely recognized that this famine fever was, 
like Mrs. Malaprop's Cerberus, " two gentlemen at 
once," one form of it being typhus or "spotted 
fever," which has now become almost extinct in civ- 
ilized communities; the other, the milder, but more 
persistent form, which, like the poor, w T e have always 
with us, called, from its resemblance to the former, 
"typhoid" (typhus-like). 

Typhus was a far more virulent, rapid, and fatal fever 
than its twin survivor, though as to the relations be- 
tween the two diseases, if any, we are quite in the dark, 
as the former practically disappeared before the days 
of bacteriology. The fact of its disappearance is both 
significant and interesting, in that it was unquestion- 
ably due to the ranker and viler forms of both munici- 
pal and individual filthiness and unsanitariness, which 
even our moderate progress in civilization has now 


abolished. There can be no question that, with a 
step higher in the scale of cleanliness, and further 
quickening of the biologic conscience, typhoid will also 

Typhus, the bubonic plague, the sweating sickness, 
were alike plagues and products of times when table- 
scraps were thrown on the dining-room floor and 
covered daily with fresh rushes for a week at a stretch, 
and fertilizer accumulated in a living-room as now in 
a modern stable. Clothing was put on for the season, 
shirts were unknown, and strong perfumes took the 
place of a bath. Michelet's famous characterization of 
the Middle Ages in one phrase as Un mille ans sans bain 
(a thousand years without a bath) was painfully ac- 

Doubtless certain habits of our own to-day will be 
regarded with equal disgust by our descendants. Ty- 
phus, by the way, may possibly be remembered by the 
dramatic "Black Assize" of Oxford, in 1577, in which 
not merely the wretched prisoners in the jail, but the 
jurors, the lawyers, the judges, and every official of the 
court were attacked, and many of them died. 

It was only in 1856 that the method of transmission 
of the disease was clearly recognized, and in 1880 that 
the bacillus was discovered and identified by the bac- 
teriologist Eberth, whose name it bears, so that it is 
only within the last thirty years that real weapons have 
been put into our hands with which to begin a fight of 
extermination against the disease. 

What is the habitat of our organism, and is it in- 
creasing its spread ? Its habitat is the entire civilized 


world, and it goes wherever civilization goes. In this 
sense its spread is increasing, but, in every other, we 
have good ground for believing that it is on the wane". 
Positive assurance, either one way or the other, is, 
of course, impossible, simply for the reason that the 
disease was not recognized until such a short time ago 
that no statistics of any real value for comparison are 
available; and, secondly, because even to-day, on 
account of its insidious character and the astonishing 
variety of its forms, and degrees of mildness and viru- 
lence, a considerable percentage of cases are yet un- 
recognized and unreported. 

It might be mentioned in passing that this statement 
applies to the alleged increase of nearly all diseases 
which are popularly believed to be modern inventions, 
like appendicitis, insanity, and cancer. We have no 
statistics more than thirty years old which are of real 
value for purposes of comparison. 

However, when it comes to the number of deaths 
from the disease, there is a striking and gratifying 
diminution for twenty years past, which is increasing 
in ratio instead of diminishing. That we are really get- 
ting control of typhoid is shown by the, at first sight, 
singular and decidedly unexpected fact that it is no 
longer a disease of cities, but of the country. The death- 
rate per thousand living in the cities of the United States 
is lower than in the rural districts. For instance, the 
mortality in the State of Maryland, outside of Balti- 
more, is two and one-half times as great as that in the 
city itself. Our period of greatest outbreak in the large 
cities is now the month of September, when city dwell- 


ers have just returned from their vacations in the pure 
and healthful country, bringing the bacilli in their 

The moral is obvious. Great cities are developing 
some sort of a sanitary conscience. Farmers and 
country districts have as yet little or none. Bad as our 
city water often is, and defective as our systems of 
sewage, they cannot for a moment compare in deadli- 
ness w r ith that most unheavenly pair of twins, the 
shallow well and the vault privy. A more ingenious 
combination for the dissemination of typhoid than this 
precious couple could hardly have been devised. The 
innocent householder sallies forth, and at an appro- 
priate distance from his cot he digs two holes, one 
about thirty feet deep, the other about four. Into the 
shallower one he throws his excreta, while upon the 
surface of the ground he flings abroad his household 
waste from the back stoop. The gentle rain from heaven 
w r ashes these various products down into the soil and 
percolates gradually into the deeper hole. When the 
interesting solution has accumulated to a sufficient 
depth, it is drawn up by the old oaken bucket or modern 
pump, and drunk. Is it any wonder that in this progres- 
sive and highly civilized country three hundred and 
fifty thousand cases of typhoid occur every year, with 
a death penalty of ten per cent ? Counting half of these 
as workers, and the period of illness as two months, 
which would be very moderate estimates, gives a loss 
of productive working time equivalent to thirty thou- 
sand years. Talk of "cheap as dirt"! It is the most 
expensive thing there is. 


Typhoid still abundantly earns its old name of 
"military fever," and its sinister victories in war are 
even more renowned than its daily triumphs in peace. 
Strange as it may seem, the deadliest enemies of the 
soldier are not bullets but bacilli, and sewage is might- 
ier than the sword. For instance, in the Franco- 
Prussian War, typhoid alone caused sixty per cent of 
all the deaths. In the Boer War it caused nearly six 
thousand deaths as compared with seven thousand five 
hundred from wounds in battle, while other diseases 
caused five thousand more. In the majority of modern 
campaigns, from two-thirds to five-sixths of all deaths 
are due to disease and not to battle. It may be that we 
sanitarians will achieve the ends of the peace congresses 
by an unexpected route, and make war a healthful and 
comparatively harmless form of national gymnastics. 
Its battle- mortality rate, for the number engaged, is 
not so very far above football now ! 

Given the bacillus, how does it get into the human 
system ? Here the evidence is so abundant and over- 
whelming that we may content ourselves with bald 
statements of fact. The three great routes of this pesti- 
lence are water, milk, and flies. Of the three, the first 
is far the most common and important. While only a 
rough statement is possible, probably eighty-five per 
cent of all cases from water, five per cent from milk, 
five per cent through flies, and five per cent through 
other channels, would fairly represent the percentage. 

That it is conveyed through water is as certain as 
that the sun rises and sets. The only embarrassment 
in proving it lies in selecting from the swarm of in- 


stances. There is the classic case of the Swiss villages 
on opposite sides of the same mountain chain, the 
second of which drew its water-supply from a spring 
that came through the mountain from a brooklet run- 
ning by the first village. Typhoid fever broke out in the 
first village, and twenty days later it appeared in the 
second village, twenty miles away on the other side of 
the mountain. Colored particles thrown into the brook 
on one side promptly appeared in the spring upon 
the other. Then there was the gruesome modern in- 
stance of Plymouth, Pennsylvania, in 1885. A single 
case of imported typhoid occurring on the watershed 
of a reservoir was followed, thirty days later, by an 
epidemic of eleven hundred cases in a population of 
eight thousand. 

An equally vivid instance came under my own obser- 
vation. A school and a penitentiary drew their water- 
supply from the same power-flume, carrying a superb 
volume of purest water from a mountain stream. Early 
in the autumn a single case of typhoid appeared in a 
small town near the head of the flume. The discharges 
were thrown into the swiftly running water. Two 
weeks later an epidemic of typhoid broke out in the 
school, and three weeks later in the penitentiary. 
An unexpected freak, however, was the appearance 
of fifteen or twenty cases in another state institution 
farther down on the same stream, which did not draw 
its water-supply from the flume, but from deep w r ells of 
tested purity. This was a puzzle, until it was found 
that, owing to a fall in the wells, the water from the 
flume had been used for sprinkling and washing pur- 


poses in the institution, being allowed to run through 
the water-pipes only at night, while the well-water was 
used in the daytime. This was enough to contaminate 
the pipes, and a small epidemic began, which promptly 
stopped as soon as the cause was suspected and the 
flume-water no longer used. 

This last instance is peculiarly interesting, as illus- 
trating how typhoid infection gets into milk, the second 
though at a long interval most frequent means 
of its spread. It does not come from the cow, for, 
fortunately, none of the domestic animals, with the 
possible exception of the cat, is subject to typhoid. 
Nor is it possible that cattle, drinking foul and even 
infected water, can transmit the bacillus in their milk. 
That superstition was exploded long ago. Every epi- 
demic of typhoid spread by milk and there are scores 
of them now on record can be traced to the handling 
of the milk by persons suffering from mild forms of 
typhoid, or engaged in waiting upon members of the 
family who are ill of the disease, or the dilution of milk 
with infected water, or even, almost incredible as it may 
seem, to such slight contamination as washing the cans 
with infected water. 

Health officers now watch like hawks for the appear- 
ance of any case of typhoid among or in the families 
of dairymen. The New York City Board of Health, for 
instance, requires the weekly filing of a certificate from 
the family physician of all dairymen that no such cases 
exist. And the more intelligent dairymen keep a vigi- 
lant eye upon any appearance of illness accompanied 
by fever among their employees, some that I have 


known even keeping a fever thermometer in the barn 
for the purpose of testing every suspicious case. How 
effective such precautions can be made may be illus- 
trated by the fact that, in the past five years, there has 
not been a single epidemic of typhoid traceable to milk 
in Greater New York, even with its inadequate corps 
of ten inspectors, and the six states they have to cover. 
The moment a single case of typhoid appears, the dairy 
or milkman supplying that customer is given a most 
rigid special inspection, and, if any source of infection 
can be discovered, the milk is shut out of New York 
City until the department is satisfied that all danger 
has been removed. One or two lessons of this sort are 
enough for a whole county of dairymen. The danger 
of transmission of typhoid through milk has been enor- 
mously exaggerated, and, as in the case of all other 
milk-borne diseases, is entirely due to filthy handling, 
and may be prevented by intelligent sanitary policing. 
Even with our present exceedingly imperfect systems, 
probably not more than between five and ten per cent 
of typhoid is transmitted in this way ; and, if the water- 
supply were kept clean, this would practically disap- 

Typhoid may not only be transmitted from the earth 
beneath and the water under the earth, but also from 
the heavens above, through the medium of flies arid 
dust. The first method is bulking larger every day, 
especially in country districts and in camps. The 
modus operandi is simplicity itself. The fly lives and 
moves and has its being in dirt. It breeds in dirt and it 
feeds on food, and, as it never wipes its feet, the interest- 


ing results can be imagined. Just to dispel any pos- 
sible doubt, plates of gelatine have been exposed where 
flies could walk on them, then placed in an incubator, 
and within forty-eight hours there was a clearly re- 
corded track of the footprints of the flies written in 
clumps of bacilli sown by their filthy feet. More defi- 
nitely, flies have been caught in the houses of typhoid 
patients, put under the microscope, and their feet, 
stomachs, and specks found swarming with typhoid 
bacilli. A single flyspeck may contain three thousand. 

Fortunately, we have a simple and effective remedy. 
We cannot disinfect tjie fly nor make him wipe his 
feet, but we can exterminate him utterly ! This sounds 
difficult, but it is n't. Like the mosquito, the fly can 
only breed in one particular kind of place, and that 
place is a heap of dirt, preferably horse manure, 
but, at a pinch, dust-bins, garbage-cans, sweepings 
under porches or behind furniture, vaults, anywhere 
that dirt is allowed to remain undisturbed for more 
than a week at a stretch. Abolish, screen, or poison 
these dirt accumulations, and flies will disappear, and 
with them not merely risks from typhoid, but half a 
dozen other diseases, as well as all sorts of filth and 
much discomfort and inconvenience. It was largely 
through flies that the disgraceful epidemic of typhoid, 
which ravaged our camps on our own soil during the 
Spanish-American War and killed many times more 
than fell by Spanish bullets, was spread. 

It is also believed that typhoid bacilli may be carried 
in the infected dust of streets and camps. Here again 
we are dealing with a dangerous public enemy to both 


health and comfort, which can and ought to be abated 
by cleanliness, oilings, and sprinklings. Typhoid ba- 
cilli are also occasionally carried by shellfish, especially 
oysters, on account of the interesting modern custom 
of planting them in bays and harbors near the mouths 
of sewers to fatten them. The cheerful motto of the 
oysterman is, "The muddier the water the fatter the 
oyster." And nowhere do the bivalves plump up more 
quickly than near the mouth of a sewer. 

The last method of transmission is by direct contact 
with the sick. This is a relatively rare means of spread, 
so much so that it is generally stated that typhoid is 
not contagious ; but it is a real source of danger and one 
against which precautions should by all means be taken. 
The only method is, of course, by the soiling of the 
hands of the nurse or other attendant, and then eating 
or touching food, or putting the fingers into the mouth 
before thoroughly cleansing. If the hands be washed 
with a strong antiseptic solution after waiting upon 
the patient, and the cheerful habit sometimes indulged 
in of putting fruit or other delicacies into the sick-room 
for a day or so, in the hope that they may tempt the 
appetite of the patient, and then taking them out and 
letting the children eat them as a treat, be abolished, 
and the nurse be not allowed to officiate in the kitchen, 
risk from this source will be done away with. 

When the bacillus has been introduced into the stom- 
ach through food or drink, it rapidly proceeds to diffuse 
itself throughout the tissues of the body. Because the 
most striking symptoms of the disease are diarrhoea, 
abdominal distention, and pain, and the most striking 


lesions after death ulcers in the small intestine, it was 
supposed that the process was confined to the abdom- 
inal organs. This is now known to be an error, as cul- 
tures and examinations made from the blood and vari- 
ous parts of the body have shown the presence of the 
typhoid bacillus in almost every organ and tissue. 
This process of scattering, or invasion of the body, 
takes from three to ten days to accomplish; and the 
first sign of trouble is usually a feeling of depression, 
with headache, and perhaps slight nausea, before any 
characteristic bowel symptoms begin to show them- 

The general invasion of the system throws an inter- 
esting sidelight upon the subject of premonitions. 
There are several well authenticated cases on record 
where individuals just before coming down with typhoid 
have been strangely impressed with a sense of impend- 
ing death, and have even gone so far as to make their 
wills and set their affairs in order. Because these strong 
impressions appeared before any clearly marked in- 
testinal symptoms of the disease, they have been put 
down in popular literature as instances of the "sec- 
ond sight," or " sixth sense," which popular superstition 
believes many of us to possess under certain circum- 
stances. Now, however, we know that the tissues of 
that individual were already swarming with bacilli, and 
his fear of impending death was simply the effect of 
his toxin-laden blood upon his brain centres. In other 
words, it was prophecy after the fact, like nearly all 
prophecies that happen to come true ; and the " pre- 
monition" was an early symptom of the disease itself. 


As it is, of course, difficult to fix the precise drink 
of water or mouthful of food in which the infection was 
conveyed, we were for a long time in doubt as to the 
length of time which it took to spread through the sys- 
tem, the "period of incubation," as it is termed, 
although we knew in a general way that it averaged 
somewhere about ten days. But, about a year ago, 
fortune was kind to us. A nurse in one of the Parisian 
hospitals, in a fit of despondency, decided to commit 
suicide. Like a true Parisienne, she would be nothing 
if not up to date, and chose, as the most recherche and 
original method of departing this life, to swallow a pure 
culture of typhoid germs, which she abstracted from 
the laboratory. Three days later she began to complain 
of headache, and within a week had developed a beauti- 
ful crop of symptoms, and a typical case of typhoid, 
from which, under modern treatment, she promptly 
recovered, a wiser and, we trust, a happier woman. 

By just what avenue the infecting bacilli go from the 
stomach into the general system we do not know. 
Metschnikoff suggests that they can only penetrate 
the intestinal wall through wounds or abrasions of the 
mucous membrane, made by intestinal worms or other 
parasites. Certain it is that the average stomach has a 
considerable degree of resisting power against them, 
for in no known civil epidemic has the number of those 
who caught the disease exceeded ten per cent of the 
total number drinking the infected water or milk. 
In one or two camps in time of war the percentage 
has risen as high as eighteen or twenty per cent of 
those exposed, but this is exceptional. However, now 


that we know that intestinal symptoms do not con- 
stitute the entire disease, and may even be entirely 
absent, we strongly suspect that many cases of slight 
depression, with feverishness, loss of appetite, and 
disturbances of the digestion, which occur during an 
epidemic, may really have been very mild cases of the 

One of the singular features of the disease is that, 
unlike many other infections, we are entirely unable to 
say what conditions or influences seem either to pro- 
tect against it or to predispose toward it. In the days 
when we believed it to be an exclusively intestinal dis- 
ease it was naturally supposed that chronic digestive 
disturbances, and especially acute attacks of bowel 
trouble or dysentery, would predispose to it, but this 
has been entirely disproved. Soldiers in barracks with 
chronic digestive disturbances, and even with dysen- 
tery, have shown no higher percentage of typhoid dur- 
ing an epidemic than others. Nor does it seem much 
more likely to occur in those who are constitutionally 
weak, or run down, or overworked, as some of the 
most violent and unmanageable cases occur in vigor- 
ous men and women, who were previously in perfect 
health. So that, although we have unquestionably a 
high degree of resistance against it, since not more than 
one in ten exposed contracts it, and only one in ten of 
those who contract it dies, we have not the least idea 
in what direction, so to speak, to build up our resist- 
ing powers in order to increase them. 

The best remedy is to destroy the disease altogether, 
and this could be done in five years by intelligent con- 


certed effort. It was at one time supposed that typhoid 
fever was a disease exclusively confined to adult life ; 
but it is now known to occur frequently in children, 
though often in such a mild and irregular form as to 
escape recognition. Something like seventy per cent 
of all cases occur between the fifteenth and the fortieth 
year, and it is, for some reason, though rarer, peculiarly 
serious and more often fatal after the fiftieth year. 

When once the outer wall has been pierced, the sack 
of the city rapidly proceeds. The bacilli multiply every- 
where, but seem for some reason to focalize chiefly 
in the alimentary canal, and especially the middle part 
of it, the small intestines. After headache, backache, 
and loss of appetite comes usually a mild diarrhoea. 
This diarrhoea is due to an attack of the bacillus or its 
toxins upon certain clumps of lymphoid tissue in the 
wall of the small intestine, known as the "patches of 
Peyer." This produces inflammation, followed by 
ulceration, which in severe cases may eat through the 
wall of a blood-vessel, causing profuse hemorrhages, 
or even perforate the bowel wall and set up a fatal 
peritonitis. The temperature begins to swing from 
two to five degrees above the normal level, following 
the usual daily vibration, and ranging from 100 degrees 
to 101 degrees in the morning up to 102 degrees to 105 
degrees in the afternoon. The face becomes flushed. 

There is usually comparatively little pain, and the 
patient lies in a sort of mild stupor, paying little atten- 
tion to his surroundings. He is much enfeebled and 
seldom cares to lift his head from the pillow. A slight 
rash appears upon the surface of the body, but this 


is so faint that it would escape attention unless care- 
fully looked for. Little groups of vesicles, containing 
clear fluid, appear upon the chest and abdomen. If 
one of these faint rose-colored spots be pricked with 
a needle and a drop of blood be drawn, typhoid bacilli 
will often be found in it, and they will also be present 
in the clear fluid of the tiny sweat blisters. 

This condition will last for from ten days to four 
weeks, the patient gradually becoming weaker and 
more apathetic, and the temperature maintaining an 
afternoon level of 102 to 104 degrees. Then, in the vast 
majority of cases, a little decline of the temperature 
will be noticed. The patient begins to take a slight 
interest in his surroundings. He will perhaps ask for 
something to drink, or something to eat, instead of 
apathetically swallowing what is offered to him. Next 
day the temperature is a little lower still, and within 
a week, perhaps, will have returned to the normal level. 
The patient has lost from twenty to forty pounds, is 
weak as a kitten, and it may be ten days after the fever 
has disappeared before he asks to sit up in bed. 

Then follows the period of return to health. The 
patient becomes a walking appetite, and, after weeks 
of liquid diet, will beg like a spoiled child for cookies 
or hard apples or pie, or something that he can set his 
teeth into. But his tissues are still swarming with the 
bacilli, and any indiscretion, either of diet, exposure, 
or exertion, at this time, may result in forming a sec- 
ondary colony, or abscess, somewhere in the lungs, the 
liver, or the muscles. He must be kept quiet and warm, 
and abundantly, but judiciously, fed, for at least three 


weeks after the disappearance of the fever, if he wishes 
to avoid the thousand and one ambuscades set by the 
retreating enemy. 

Now, what has happened when recovery begins? 
One would suppose that either the bacilli had poisoned 
themselves, exhausted the supplies of nourishment in 
the body of the patient, so that the fever had " burnt 
itself out," as we used to say, or that the tissues had 
rallied from the attack and destroyed or thrown out 
the invaders. But, on the contrary, we find that our 
convalescent patient, even after he is up and walking 
about, is still full of the bacilli. 

To put it very crudely, what has really happened is 
that the body has succeeded in forming such antidotes 
against the poison of the bacilli that, although they 
may be present in enormous numbers, they can no 
longer produce any injurious effect. In other words, 
it has acquired immunity against this particular germ 
and its toxin. In fact, one of our newest and most reli- 
able tests for the disease consists in a curious " clump- 
ing" or paralyzing power over cultures of the Bacillus 
typhosus, shown by a drop of the patient's blood, even 
as early as the seventh or eighth day of the illness. 
And, while it is an immensely difficult and compli- 
cated subject, we are justified in saying that this im- 
munity is not merely a substance formed in the body, 
the stock of which will shortly become exhausted, but 
a faculty acquired by the body-cells, which they will 
retain, like other results of education, for years, and 
even for life. When once the body has learned the 
wrestling trick of throwing and vanquishing a particu- 


lar germ or bacillus, it no longer has much to dread 
from that germ. This is why the same individual is 
seldom attacked the second time by scarlet fever, 
measles, typhoid, and smallpox. 

While, however, the individual may be entirely im- 
mune to the germs of a given disease, he may carry 
them in his body in enormous numbers, and infect 
others while escaping himself. 

This is peculiarly true of typhoid, and we are begin- 
ning to extend our sanitary care over recovered patients, 
not merely to the end of acute illness, but for the period 
of at least a month after they have apparently recov- 
ered. Several most disquieting cases are on record of 
so-called "typhoid carriers," or individuals who, 
having recovered from the disease itself, carried and 
spread the infection wherever they went for months 
and even years afterward. This, however, is probably 
a rare state of affairs, though a recent German health 
bulletin reports the discovery of some twenty cases 
during the past year. The lair of the bacilli is believed 
to be the gall-bladder. 

As to treatment, it may be broadly stated that all 
authorities and schools are for once practically 
agreed : 

First, that we have no known specific drug for the 
cure of the disease. 

Second, that we are content to take a leaf out of na- 
ture's book, and follow so to speak her instinctive 
methods: first of all, by putting the patient to bed the 
moment that a reasonable suspicion of the disease is 
formed ; this conserves his strength, and greatly dimin- 


ishes the danger of serious complications; cases of 
" walking typhoid " have among the highest death-rates ; 
second, by meeting the great instinctive symptom of fe- 
ver patients since the world began, thirst, encouraging 
the patient to drink large quantities of water, taking 
care, of course, that the water is pure and sterile. The 
days when we kept fever patients wrapped up to their 
necks in woolen blankets in hot, stuffy rooms, and rigor- 
ously limited the amount of water that they drank - in 
other words, fought against nature in the treatment of 
disease have passed. A typhoid-fever patient now is 
not only given all he wants to drink, but encouraged 
to take more, and some authorities recommend an 
intake of at least three or four quarts, and, better, six 
and eight quarts a day. This internal bath helps not 
only to allay the temperature, but to make good the 
enormous loss by perspiration from the fevered skin, 
and to flush the toxins out of the body. 

Third, by liberal and regular feeding chiefly with 
some liquid or semi-liquid food, of which milk is the 
commonest form. The old attitude of mind represented 
by the proverb, "Feed a cold and starve a fever," has 
completely disappeared. One of the fathers of modern 
medicine asked on his death-bed, thirty years ago, that 
his epitaph should be, " He fed fevers." 

Fourth. We respond to the other great thirst of 
fever patients, for coolness, by sponge baths and tub 
baths, whenever the temperature rises above a certain 

Simple as these methods sound, they are extremely 
troublesome to put into execution, and require the 


greatest skill and judgment in their carrying out. But 
intelligent persistence in the careful elaboration of 
these methods of nature has resulted in already cutting 
the death-rate in two, from fifteen or twenty per 
cent to less than ten per cent, and where the full 
rigor of the tub bath is carried out it has been brought 
down to as low as five per cent. 

Meanwhile the bacteriologists are steadily at work 
on a vaccine or antitoxin. Wright, of the English Army 
Medical Staff, has already secured a serum, which has 
given remarkable results in protecting regiments sent 
out to South Africa and, other infected regions. Chante- 
messe has imported some six hundred successive cases 
treated with an antitoxin, whose mortality was only 
about a third of the ordinary hospital rate, and the 
future is full of promise. 



THAT was a dark and stern saying, " Without the 
shedding of blood there is no remission,'* and, like 
all the words of the oracles, of limited application. But 
it proves true in some unexpected places outside of the 
realm of theology. Was there something prophetic in 
the legend that it was only by the sprinkling of the 
blood of the Paschal Lamb above the doorway that 
the plague of the firstborn could be stayed ? To-day 
the guinea-pig is our burnt offering against a plague 
as deadly as any sent into Egypt. 

Scarcely more than a decade ago, as the mother sat 
by the cradle of her firstborn, musing over his future, 
one moment fearfully reckoning the gauntlet of risks 
that his tiny life had to run, and the next building rosy 
air-castles of his happiness and success, there was one 
shadow that ever fell black and sinister across his tiny 
horoscope. Certain risks there were which were almost 
inevitable, initiation ceremonies into life, mild expia- 
tions to be paid to the gods of the modern underworld, 
the diseases of infancy and of childhood. Most of these 
could be passed over with little more than a temporary 
wrinkle to break her smile. They were so trivial, so 
comparatively harmless : measles, a mere reddening of 
the eyelids and peppering of the throat, with a head- 
ache and purplish rash, dangerous only if neglected; 


chicken-pox, a child's-play at disease; scarlatina, a 
little more serious, but still with the chances of twenty 
to one in favor of recovery; diphtheria ah! that drove 
the smile from her face and the blood from her lips. 
Not quite so common, not so inevitable as a prospect, 
but, as a possibility, full of terror, once its poison had 
passed the gates of the body fortress. The fight be- 
tween the Angel of Life and the Angel of Death was 
waged on almost equal terms, with none daring to say 
which would be the victor, and none able to lift a hand 
with any certainty to aid. 

Nor was the doctor, in much happier plight. Even 
when the life at stake was not one of his own loved ones, 
though from the deadly contagiousness of the disease 
it sadly often was (I have known more doctors made 
childless by diphtheria than by any other disease ex- 
cept tuberculosis) , he faced his cases by the hun- 
dred instead of by twos and threes. The feeling of 
helplessness, the sense of foreboding, with which we 
faced every case was something appalling. Few of us 
who have been in practice twenty years or more, or even 
fifteen, will ever forget the shock of dismay which ran 
through us whenever a case to which we had been sum- 
moned revealed itself to be diphtheria. Of course, 
there was a fighting chance, and we made the most of 
it; for in the milder epidemics only ten to twenty per 
cent of the patients died, and even in the severest a 
third of them recovered. But what " turned our liver 
to water" as the graphic Oriental phrase has it 
was the knowledge which, like Banquo's ghost, would 
not down, that while many cases would recover of 


themselves, and in many border-line ones our skill 
would turn the balance in favor of recovery, yet if the 
disease happened to take a certain sadly familiar, viru- 
lent form we could do little more to stay its fatal course 
than we could to stop an avalanche, and we never knew 
when a particular epidemic or a particular case would 
take that turn. "Black" diphtheria was as deadly as 
the Black Death of the Middle Ages. 

The disease which caused all this terror and havoc 
is of singular character and history. It is not a modern 
invention or development, as is sometimes believed, for 
descriptions are on record of so-called " Egyptian ulcer 
of the throat" in the earliest centuries of our era; and 
it would appear to have been recognized by both Hip- 
pocrates and Galen. Epidemics of it also occurred in 
the Middle Ages; and, coming to more recent times, 
one of the many enemies which the Pilgrim Fathers 
had to fight was a series of epidemics of this "black 
sore throat," of particularly malignant character, in the 
seventeenth century. Nevertheless, it does not seem to 
have become sufficiently common to be distinctly 
recognized until it was named as a definite disease, and 
given the title which it now bears, by the celebrated 
French physician, Bretonneau, about eighty years ago. 
Since then it has become either more widely recognized 
or steadily more prevalent, and it is the general opinion 
of pathologists that the disease, up to some thirty or 
forty years ago, was steadily increasing, both in fre- 
quency and in severity. 

So that we have not to deal with a disease which, like 
the other so-called diseases of childhood, has gradually 


become milder and milder by a sort of racial vaccina- 
tion, with survival of the less susceptible, but one which 
is still full of virulence and of possibilities of future 

Unlike the other diseases of childhood, also, one 
attack confers no positive immunity for the future, 
although it greatly diminishes the probabilities; and, 
further, while adults do not readily or frequently catch 
the disease, yet when they do the results are apt to be 
exceedingly serious. Indeed, we have practically come 
to the conclusion that one of the main reasons why 
adults do not develop diphtheria so frequently as chil- 
dren, is that they are not brought into such close and 
intimate contact with other children, nor are they in 
the habit of promptly and indiscriminately hugging 
and kissing every one who happens to attract their 
transient affection, and they have outgrown that cheer- 
ful spirit of comradeship which leads to the sharing of 
candy in alternate sucks, and the passing on of slate- 
pencils, chewing-gum, and other objets d'art from hand 
to hand, and from mouth to mouth. Statistics show 
that of nurses employed in diphtheria wards, before the 
cause or the exact method of contagion was clearly un- 
derstood, nearly thirty per cent developed the disease; 
and even with every modern precaution there are few 
diseases which doctors more frequently catch from 
their patients than diphtheria. It is a significant fact 
that the risk of developing diphtheria is greatest 
precisely at the ages when there is not the slightest 
scruple about putting everything that may be picked 
up into the mouth, namely, from the second to the 


fifth year, and diminishes steadily as habits of clean- 
liness and caution in this regard are developed, even 
though no immunity may have been gained by a mild 
or slight attack of the disease. The tendency to dis- 
courage and forbid the indiscriminate kissing of chil- 
dren, and the crusade against the uses of the mouth as a 
pencil-holder, pincushion, and general receptacle for 
odds and ends, would be thoroughly justified by the 
risks from diphtheria alone, to say nothing of tuber- 
culosis and other infections. 

In addition to being almost the only common disease 
of childhood which is not mild and becoming milder, 
diphtheria is unique in another respect, and that is its 
point of attack. Just as tuberculosis seizes its victims 
by the lungs, and typhoid fever by the bowels, diph- 
theria like the weasel grips at the throat. Its 
bacilli, entering through the mouth and gaining a foot- 
hold first upon the tonsils, the palate, or back of the 
throat (pharynx), multiply and spread until they 
swarm down into the larynx and windpipe, where their 
millions, swarming in the mesh of fibrin poured out by 
the outraged blood-vessels, grow into the deadly false 
membrane which fills the air-tube and slowly strangles 
its victim to death. 

The horrors of a death like that can never fade from 
the memory of one who has once seen it, and will out- 
weigh the lives of a thousand guinea-pigs. No wonder 
there was such a widespread and peculiar horror of the 
disease, as of some ghostly thug or strangler. 

But not all of the dread of diphtheria went under its 
own name. Most of us can still remember when the 


commonest occupant of the nursery shelf was the bottle 
of ipecac or soothing-syrup as a specific against croup. 
The thing that most often kept the mother or nurse of 
young children awake and listening through the night- 
watches was the sound of a cough, and the anxious 
waiting to hear whether the next explosion had a 
"croupy" or brassy sound. It was, of course, early 
recognized that there were two kinds of croup, the so- 
called "spasmodic" and the "membranous," the for- 
mer comparatively common and correspondingly 
harmless, the latter one of the deadliest of known dis- 
eases. The fear that made the mother's heart leap into 
her mouth as she heard the ringing croup-cough was 
lest it might be membranous, or, if spasmodic, might 
turn into the deadly form later. To-day most young 
mothers hardly know the name of wine of ipecac or 
alum, and the coughs of young children awaken little 
more terror than a similar sound in an adult. Croup 
has almost ceased to be one of the bogies of the nursery. 
And why ? Because membranous croup has been dis- 
covered to be diphtheria, and children will not develop 
diphtheria unless they have been exposed to the con- 
tagion, while, if they should be, we have a remedy 
against it. 

He was a bold man who first ventured to announce 
this, and for years the battle raged hotly. It was early 
admitted that certain cases of so-called membranous 
croup in children occurred after or while other members 
of the family or household had diphtheria ; and for a 
time the opposing camps used such words as " sporadic" 
or scattered croup, which was supposed to come of 


itself, and "epidemic'* or contagious croup, which was 
diphtheria. Now, however, these distinctions are swept 
away, and boards of health require isolation and quar- 
antine against croup exactly as against any other form 
of diphtheria. 

Cases of fatal croup still occasionally occur which 
cannot be directly traced to other cases of diphtheria, 
but the vast majority of them are clearly traceable to 
infection, usually from some case in another child, 
which was so mild that it was not recognized as diph- 
theria until the baby became "croupy" and search 
was made through the family throats for the bacilli. 

For years we were in doubt as to the cause of diph- 
theria. Half a dozen different theories were advanced, 
bad sewerage, foul air, overcrowding; but it was not 
until shortly after the Columbus-like discovery, by 
Robert Koch, of the new continent of bacteriology, that 
the germ which caused it was arrested, tried, and found 
guilty, and our real knowledge of and control over the 
disease began. This was in 1883, when the bacteriolo- 
gist Klebs discovered the organism, followed a few 
months later (in 1884) by Loffler, who made valuable 
additions to our knowledge of it; so that it has ever 
since been known as the Klebs-Loffler bacillus. This 
put us upon solid ground, and our progress was both 
sure and rapid : in ten years our knowledge of the causa- 
tion, the method of spread, the mode of assault upon 
the body-fortress, and last, but not least, the cure, 
stood out clear cut as a die, a model and a prophecy 
of what may be hoped for in most other contagious 


Great as is the credit to which bacteriologists are 
entitled for this splendid piece of scientific progress, 
there was another co-laborer, a silent partner, with 
them in all this triumph, an unsung hero and martyr 
of science who deserves his meed of praise the tiny 
guinea-pig. He well deserves his niche in the temple of 
fame ; and as other races and ages have worshiped the 
elephant, the snake, and the sacred cow, so this age 
should erect its temples to the guinea-pig. From one 
of the most trifling and unimportant, kept merely 
as a pet and curiosity by the small boys of all ages, 
he has become, after the horse, the cow, the pig, and 
the sheep, easily our most useful and important domes- 
tic animal. It may be urged that he deserves no credit, 
since his sacrifice though of inestimable value 
was entirely involuntary on his own part; but this 
should only make us the more deeply bound to acknow- 
ledge our obligation to him. 

By a stern necessity of fate, which no one regrets 
more keenly than the laboratory workers themselves, 
the guinea-pig has had to be used as a stepping-stone 
for every inch of this progress. Upon it were conducted 
every one of the experiments whose results widened 
our knowledge, until we found that this bacillus and 
no other would cause diphtheria ; that instead of get- 
ting, like many other disease-germs, into the blood, it 
chiefly limited itself to growing and multiplying upon a 
comparatively small patch of the Jpody-surface, most 
commonly of the throat; that most of its serious and 
fatal results upon the body were produced, not by the 
entrance of the germs themselves into the blood, but 


by the absorption of the toxins or poisons produced 
by them on the moist surface of the throat, just as the 
yeast plant will produce alcohol in grape juice or sweet 

Here was a most important clew. It was not neces- 
sary to fight the germs themselves in every part of the 
body, but merely to introduce some ferment or chemical 
substance which would have the power of neutralizing 
their poison. Instantly attention was turned in this 
direction, and it was quickly found that if a guinea-pig 
were injected with a very small dose of the diphtheria 
toxin and allowed to recover, he would then be able 
to throw off a still larger dose, until finally, after a 
number of weeks, he could be given a dose which would 
have promptly killed him in the beginning of the experi- 
ments, but which he now readily resisted and recovered 
from. Evidently some substance was produced in his 
blood which was a natural antidote for the toxin, and 
a little further search quickly resulted in discovering 
and filtering out of his body the now famous antitoxin. 
A dose of this injected into another guinea-pig suffering 
from diphtheria would promptly save its life. 

Could this antitoxin be obtained in sufficient amounts 
to protect the body of a human being ? The guinea-pig 
was so tiny and the process of antitoxin-forming so 
slow, that we naturally turned to larger animals as a 
possible source, and here it was quickly found that not 
only would the goat and the horse develop this antidote 
substance very quickly and in large amounts, but that 
a certain amount of it, or a substance acting as an anti- 
toxin, was present in their blood to begin with. Of the 


two, the horse was found to give both the stronger anti- 
toxin and the larger amounts of it, so that he is now 
exclusively used for its production. 

After his resisting power had been raised to the 
highest possible pitch by successive injections of in- 
creasing doses of the toxin, and his serum (the watery 
part of the blood which contains the healing body) 
had been used hundreds and hundreds of times to save 
the lives of diphtheria-stricken guinea-pigs, and had 
been shown over and over again to be not merely magi- 
cally curative but absolutely harmless, it was tried with 
fear and trembling upon a gasping, struggling, suffo- 
cating child, as a last possible resort to save a life other- 
wise hopelessly doomed. Who could tell whether the 
"heal-serum," as the Germans call it, would act in a 
human being as it had upon all the other animals? 
In agonies of suspense, vibrating between hope and 
dread, doctors and parents hung over the couch. What 
was their delight, within a few hours, to see the muscles 
of the little one begin to relax, the fatal blueness of its 
lips to diminish, and its breathing become easier. In 
a few hours more the color had returned to the ashen 
face and it was breathing quietly. Then it began to 
cough and to bring up pieces of the loosened membrane 
that had been strangling it. Another dose was eagerly 
injected, and within twenty-four hours the child was 
sleeping peacefully out of danger. And the most 
priceless and marvelous life-saving weapon of the cen- 
tury had been placed in the hand of the physician. 

Of course there were many disappointments and 
failures in the earlier cases. Our first antitoxins were 


too weak and too variable. We were afraid to use them 
in sufficient doses. Often their injection would not be 
consented to until the case had become hopeless. But 
courage and industry have conquered these difficulties 
one after another, until now the fact that the prompt 
and intelligent use of antitoxin will effect a cure of from 
ninety to ninety-five per cent of all cases of diphtheria 
is as thoroughly established as any other fact in medi- 
cine. The mass of figures from all parts of the world 
in support of its value has become so overwhelming 
that it is neither possible nor necessary to specify them 
in detail. The series of Bayeaux, covering two hundred 
and thirty thousand cases of diphtheria, chiefly from 
hospitals and hence of the severest type, showing that 
the death-rate had been reduced from over fifty-five per 
cent to below sixteen per cent already, and that this 
decrease was still continuing, will serve as a fair sample. 
Three-quarters of even this sixteen per cent mortality 
is due to delay in the administration of the antitoxin, 
as is vividly shown in thousands of cases now on record, 
classified according to the day of the disease on which 
the antitoxin was given, of which MacCombie's "Re- 
port of the London Asylums Board" is a fair type. 
Of one hundred and eighty-seven cases treated the first 
day of the disease, none died ; of eleven hundred and 
eighty-six injected on the second day of the disease, 
four and a half per cent died ; of twelve hundred and 
thirty-three not treated until the third day of the dis- 
ease, eleven per cent died ; of nine hundred and sixty- 
three cases escaping treatment until the fourth day, 
seventeen per cent died ; while of twelve hundred and 


sixty not seen until the fifth day, twenty per cent died. 
In other words, the chances for cure by the anti- 
toxin are in precise proportion to the earliness with 
which it is administered, and are over four times as 
great during the first two days of the disease as they 
are after the fourth day. One "stick" in time saves 

This brings us sharply to the fact that the most im- 
portant factor in the cure of diphtheria, just as in the 
case of tuberculosis, is early recognition. How can this 
be secured ? Here again the bacteriologist comes to 
our relief, and we needed his aid badly. The symptoms 
of a mild case of diphtheria for the first two, or even 
three, days are very much like those of an ordinary sore 
throat. As a rule, even the well-known membrane does 
not appear in sufficient amounts to be recognizable 
by the naked eye until the middle of the second, or 
sometimes even of the third, day. By any ordinary 
means, then, of diagnosis, we would often be in doubt 
as to whether a case were diphtheria or not, until it was 
both well advanced and had had time to infect other 
members of the family. With the help of the labora- 
tory, however, we have a prompt, positive, and simple 
method of deciding at the very earliest stage. We 
merely take a sterilized swab of cotton on the end of a 
wire, rub it gently over the surface of the throat and 
tonsils, restore it to its glass tube, smearing it over 
the surface of some solidified blood-serum placed at the 
bottom of the tube, close the tube and send it to the 
nearest laboratory. The culture is put into an incubator 
at body heat, the germs sown upon the surface of the 


blood-serum grow and multiply, and in twelve hours a 

positive diagnosis can be made by examining this 
growth with a microscope. Often, just smearing the 
mucus swabbed out of the throat over the surface of a 
glass slide, staining this smear, and putting it under a 
microscope, will enable us to decide within an hour. 
These tubes are now provided by all progressive city 
boards of health, and can be had free of charge at 
depots scattered all over the city, for use in any doubtful 
case, within half an hour. Twelve hours later a free 
report can be had from the public laboratory. If every 
case of suspicious sore throat in a child were promptly 
swabbed out, and a smear from the swab examined at 
a laboratory, it would not be long before diphtheria 
would be practically exterminated, as smallpox has 
been by vaccination, and this is what we are working 
toward and looking forward to. 

Our knowledge of the precise cause of diphtheria, 
the Klebs-Loffler bacillus, has furnished us not only 
with the cure, but also with the means of preventing 
its spread. While under certain circumstances, par- 
ticularly the presence of moisture and the absence of 
light, this germ may live and remain virulent for weeks 
outside of the body, careful study of its behavior under 
all sorts of conditions has revealed the consoling fact 
that its vitality outside of the human or some other 
living animal body is low ; so that it is relatively seldom 
carried from one case to another by articles of clothing, 
books, or toys, and comparatively seldom even through 
a third party, except where the latter has come into 
very close contact with the disease, like a doctor, a 


nurse, or a mother, or without disrespect to the pre- 
ceding a pet cat or dog. 

More than this, the bacillus must chiefly be trans- 
mitted in the moist condition and does not float in the 
air at all, clinging only to such objects as may have 
become smeared with the mucus from the child's 
throat, as by being coughed or sneezed upon. As with 
most of our germ-enemies, sunlight is its deadliest foe, 
and it will not live more than two or three days exposed 
to sunshine. So the principal danger against which we 
must be on our guard is that of direct personal contact, 
as in kissing, in the use of spoons or cups in common, 
in the interchange of candy or pencils, or through hav- 
ing the hands or clothing sprayed by a cough or a 

The bacillus comparatively seldom even gets on the 
floor or walls of a room where reasonable precautions 
against coughing and spitting have been taken; but 
it is, of course, advisable thoroughly to disinfect and 
sterilize the room of a patient and all its contents with 
corrosive sublimate and formalin, as a number of cases 
are on record in which the disease has been carried 
through books and articles of clothing which had been 
kept in damp, dark places for several months. The 
chief method of spread is through unrecognized mild 
cases of the disease, especially of the nasal form. For 
this reason boards of health now always insist upon 
smears being made from the throats and noses of every 
other child in the family or house where a case of diph- 
theria is recognized. No small percentages of these are 
found to be suffering from a mild form of the disease, 


so slight as to cause them little inconvenience and no 
interference with their attending school. Unfortu- 
nately, a case caught from one of these mild forms may 
develop into the severest laryngeal type. If a child is 
running freely at the nose, keep it at home or keep your 
own child away from it. A profuse nasal discharge is 
generally infectious, in the case of influenza or other 
"colds," if not of diphtheria. 

This also emphasizes the necessity for a thorough 
and expert medical inspection of school-children, to 
prevent these mild cases from spreading disease and 
death to their fellows. By an intelligent combination 
of the two methods, home examination of every in- 
fected family and strict school inspection, there is little 
difficulty in stamping out promptly a beginning infec- 
tion before it has had time to reach the proportions 
of an epidemic. 

One other step makes assurance doubly sure, and 
that is the prompt injection of all other children and 
young adults living in the family, where there is a case 
of diphtheria, with small doses of the antitoxin for pre- 
ventive purposes. Its value in this respect has been only 
secondary to its use as a cure. There are now thousands 
of cases on record of children who had been exposed 
to diphtheria or were in hospitals where they were in 
danger of becoming exposed to it, with the delightful 
result that only a very small per cent of those so pro- 
tected developed the disease, and of these not a single 
one died ! This protective vaccination, however, cannot 
be used on a large scale, as in the case of smallpox, 
for the reason that the period of protection is a com- 


paratively short one, probably not exceeding two or 
three weeks. 

Suppose that, in spite of all our precautions, the dis- 
ease has gained a foothold in the throat, what will be 
its course ? This will depend, first of all, upon whether 
the invading germs have lodged in their commonest 
point of attack, the tonsils, palate, and upper throat, 
or have penetrated down the air-passages into the lar- 
ynx or voice-organ. In the former, which is far the 
commoner case, their presence will cause an irritation 
of the surface cells which brings out the leucocyte cav- 
alry of the body to the, defense, together with squads 
of the serum or watery fluid of the blood containing 
fibrin. These, together with the surface-cells, are 
rapidly coagulated and killed by the deadly toxin ; and 
their remains form a coating upon the surface, which 
at first is scarcely perceptible, a thin, grayish film, 
but which in the course of twenty-four to forty-eight 
hours rapidly thickens to the well-known and dreaded 
false membrane. Before, however, it has thickened in 
more than, occasional spots or patches, the toxin has 
begun to penetrate into the blood, and the little patient 
will complain of headache, feverishness, and backache, 
often indeed, usually before any very marked 
soreness in the throat is complained of. Roughly 
speaking, attacks of sore throat, which begin first of all 
with well-marked soreness and pain in the throat, fol- 
lowed later by headache, backache, and fever, are not 
very likely to be diphtheria. The bacilli multiply and 
increase in their deadly mat on the surface of the throat, 
larger and larger amounts,of the poison are poured into 


the blood, the temperature goes up, the headache 
increases, the child often begins to vomit, and becomes 
seriously ill. The glands of the neck, in their efforts 
to arrest and neutralize the poison, become swollen 
and sore to the touch, the breath becomes foul from 
the breaking down of the membrane in the throat, the 
pulse becomes rapid and weak from the effect of the 
poison upon the heart, and the dreaded picture of 
the disease rapidly develops. 

This process in from sixty to eighty per cent of cases 
will continue for from three to seven days, when a check 
will come and the condition will gradually improve. 
This is a sign that the defensive tissues of the body 
have succeeded in rallying their forces against the at- 
tack, and have poured out sufficient amounts of their 
natural antitoxin to neutralize the poisons poured in 
by the invaders. The membrane begins to break down 
and peel off the throat, the temperature goes down, the 
headache disappears, the swelling in the glands of the 
neck may either subside or go on to suppuration and 
rupture, but within another week the child is fairly 
on the way to recovery. 

Should the invaders, however, have secured a foot- 
hold in the larynx, then the picture is sadly different. 
The child may have even less headache, temperature, 
and general sense of illness; but he begins to cough, 
and the cough has a ringing, brassy sound. Within 
forty-eight, or even twenty-four, hours he begins to 
have difficulty in respiration. This rapidly increases 
as the delicate tissues of the larynx swell under the 
attack of the poison, and the very membrane which is 


created in an attempt at defense becomes the body's 
own undoing by increasing the blocking of the air-pas- 
sages. The difficulty of breathing becomes greater and 
greater, until the little victim tosses continually from 
side to side in one constant, agonizing struggle for 
breath. After a time, however, the accumulation of 
carbon dioxide in the blood produces its merciful nar- 
cotic effect, and the struggles cease. The breathing be- 
comes shallower and shallower, the lips become first 
blue, then ashy pale, and the little torch of life goes 
out with a flicker. This was what we had to expect, 
in spite of our utmost effort, in from seventy to ninety 
per cent of these laryngeal cases, before the days of the 
blessed antitoxin. Now we actually reverse these per- 
centages, prevent the vast majority of cases from de- 
veloping serious laryngeal symptoms at all, and save 
from seventy to eighty per cent of those who do. 

Our only resource in this form of the disease used 
to be by mechanical or surgical means, opening the 
windpipe below the level of the obstruction and insert- 
ing a curved silver tube the so-called tracheotomy 
operation ; or later, and less heroic, by pushing forcibly 
down into the larynx, and through and past the obstruc- 
tion at the vocal cords, a small metal tube through 
which the child could manage to breathe. This was 
known as intubation. But these were both distressing 
and painful methods, and, what was far worse, piti- 
fully broken reeds to depend upon. In spite of the 
utmost skill of our surgeons, from fifty to eighty per 
cent of cases that were tracheotomized, and from forty 
to sixty per cent of those that were intubated, died. 


In many cases they were enabled to breathe, their 
attacks of suffocation were relieved but still they 

This leads us to the most important single fact about 
the course of the disease, and that is that the chief 
source of danger is not so much from direct suffocation 
as from general collapse, and particularly failure of 
the heart. 

This has given us two other data of great importance 
and value, namely, that while the immediate and great- 
est peril is over when the membrane has become loos- 
ened and the temperature has begun to subside, in 
both ordinary throat and in laryngeal forms of the 
disease, the patient is by no means out of danger. 
While the antitoxins poured out by his body have com- 
pletely defeated the invading toxins in the open field of 
the blood, yet almost every tissue of the body is still 
saturated with these latter and has often been seriously 
damaged by them before their course was checked. 
For instance, nearly two-thirds of our diphtheria cases, 
which are properly examined, will show albumin in the 
urine, showing that the kidney-cells have been attacked 
and poisoned by the toxin. This may go on to a fatal 
attack of uremia; but fortunately, not commonly, far 
less so than in scarlet fever. The kidneys usually 
recover completely, but this may take weeks and 
months. Again, many cases of diphtheria will show 
a weak and rapid pulse, which will persist for weeks 
after the patient has apparently recovered ; and if the 
little ones are allowed to sit up too soon, or to indulge 
in any sudden movements or muscular strains, this 


weak and rapid pulse will suddenly change into an 
attack of heart failure and, possibly, fatal collapse. 
This, again, illustrates the saturation of the poison, 
as these effects are now known to be due in part to a 
direct poisoning of the muscle of the heart itself, and 
later to serious damage done to the nerves controlling 
the heart, chiefly the pneumo-gastric. Moral: Keep 
the little patient in bed for at least two weeks or, better, 
three. He will have to spend a month or more in quar- 
antine, anyway. 

Last of all, and by no means least interesting, are 
the effects which are produced upon the nervous system. 
One day, while the child is recovering, and is possibly 
beginning to sit up in bed, a glass of milk is handed to 
him. The little one drinks it eagerly and attempts to 
swallow, but suddenly it chokes, half strangles, and 
back comes the milk, pouring out through the nostrils. 
Paralysis of the soft palate has occurred from poison- 
ing of the nerves controlling it, caused by direct pene- 
tration of the toxin. Sometimes the muscles of the 
eye become paralyzed and the little one squints, or 
can no longer see to read. 

Fortunately, most of these alarming results go only 
to a certain degree, and then gradually fade away and 
disappear ; but this may take months or even longer. 
In a certain number, however, the nerves of respira- 
tion, or those controlling the heart-beat, become affected, 
and the patient dies suddenly from heart failure. 

This strange after-effect upon the nervous system, 
which was first clearly noticed in diphtheria and 
syphilis, has now been found to occur in lesser 


degree in a large number of our infectious diseases, so 
that many of our most serious paralyses and other dis- 
eases of the nervous system are now traceable to such 

These effects of the diphtheria toxin are also of inter- 
est for a somewhat unexpected reason, since it has been 
claimed that they are effects of the antitoxin, by those 
who are opposed to its use. Every one of them was well 
recognized as a possible result of diphtheria long before 
the antitoxin was discovered, and every one of them 
can be readily produced by injections of diphtheria 
bacilli or their toxin into animals. 

It is quite possibly true that there are more cases 
of nerve-poisoning (neuritis) and of paralysis following 
diphtheria than there were before the use of antitoxin, 
but that is for the simple and sufficient reason that there 
are more children left alive to display them ! And be- 
tween a child with a temporary squint and a dead child 
few mothers would hesitate long in their choice. 



WHY is a disease a disease of childhood ? First 
and fundamentally, because that is the earliest 
period at which a human being can have it. But the 
problem goes deeper than this. There is no more inter- 
esting and important group of diseases in the whole 
realm of pathology than those which we calmly dub 
"the diseases of childhood," and thereby dismiss 
to the limbo of unavoidable accidents and discomforts, 
like flies, mosquitoes, and stubbed toes, which are best 
treated with a shrug of the shoulders and such stoic 
philosophy as we can muster. They are interesting, 
because the moment we begin to study them intelli- 
gently we stumble upon some of the profoundest and 
most far-reaching problems of resistance to disease; 
important, because, trifling as we regard them, and 
indeed largely just because we so regard them, they 
kill, or handicap for life, more children in civilized com- 
munities than the most deadly pestilence. Measles, for 
instance, according to the last United States census, 
causes yearly nearly thirteen thousand deaths, while 
smallpox causes so few that it is not listed among the 
important causes of death. Scarlet fever causes sixty- 
three hundred and thirty-three deaths, as compared 


with barely five thousand from appendicitis and the 
same number from rheumatism. Whooping-cough 
causes ninety-nine hundred and fifty-eight deaths, more 
than double the mortality from diabetes and nearly 
equal to that of malarial fever. 

In medicine, as in war, the gravest and deadliest 
mistake that you can make is to despise your enemy. 
These trivial disorders, these trifling ailments, which 
every one takes as a matter of course, and expects to go 
through with, like teething, tight shoes, and learning 
to smoke, sweep away every year in these United States 
the lives of from forty to fifty thousand children, reach- 
ing the bad eminence of fifth upon our mortality lists, 
only consumption, pneumonia, heart disease, and 
diarrhceal diseases ranking above them. Of course, 
it is obvious that these diseases outrank many other 
more serious ones among the " captains of the men of 
death," largely upon the familiar principle of the old 
riddle, whereby the white sheep eat more grass than 
the black, " because there are more of them." 

While only a relatively small percentage of us ever 
have the bad luck to be attacked by typhoid fever, 
rheumatism, or appendicitis, to say nothing of cholera 
and smallpox, the vast majority of us have gone 
through two or more of these diseases of childhood; 
so that, though the death-rate of each and all of them 
is low, yet the number of cases is so enormous that the 
absolute total mounts high. But the pity and, at the 
same time, the practical importance of this heavy death- 
roll is that at least two-thirds of it is absolutely prevent- 
able, and by the exercise of only a very moderate 


amount of intelligence and vigilance. It is, of course, 
obvious that in a group of diseases which numbers its 
victims literally by the million every year there will 
inevitably occur a certain minute percentage of fatal 
results due to what might be termed unavoidable 
causes, like a badly nourished condition of the child 
attacked, unusual circumstances preventing proper 
shelter or nursing, or an exceptional virulence of 
the disease, such as will occur in two or three cases 
of every thousand in even the most trifling infectious 
malady. But even after making liberal allowance for 
what might be termed the unavoidable fatalities, at 
least two-thirds, and more probably nine-tenths, of the 
deaths from children's diseases might be prevented 
upon two grounds : 

First, that they are contagious and absolutely de- 
pendent upon a living germ, whose spread can be pre- 
vented ; and secondly, and practically even more im- 
portant, that more than half the deaths from them are 
due, not to the disease itself, but to complications 
occurring during the period of recovery, caused, for 
the most part, by gross carelessness on the part of the 
mother or nurse. A large majority, for instance, of 
the nearly thirteen thousand deaths attributed to 
measles are due to bronchitis, caught by letting the 
child go out-of-doors too soon after recovery, which 
means, of course, either a chill falling upon the irritated 
and weakened bronchial mucous membrane, or an 
infection by one of the score of disease-germs, such as 
those of influenza, pneumonia, bronchitis, and even 
tuberculosis, which are continually lying in wait for just 


such an emergency as this just such a weakening of 
the vital resistance. 

It is a sadly familiar statement in the history of fatal 
cases of tuberculosis that the trouble " began with an 
attack of measles," or whooping-cough, or a bad cold, 
and was mistaken for a mere "hanging on" of one of 
these milder maladies until it had gained a foothold that 
there was no dislodging. As breakers of the wall of the 
hollow square of the body-cells, drawn up to resist the 
cavalry charges of tuberculosis, pneumonia, and rheu- 
matism, few can be compared in deadliness with the 
diseases of childhood and " common colds." 

Further, while all of them except scarlet fever have 
a mortality so low that it might almost be described as 
what the French delicately term une quantite negli- 
geable, yet a surprisingly large number of the survivors 
do not escape scot-free, but bear scars which they may 
carry to their graves, or which may even carry them 
to that bourne later. Again, the actual percentage of the 
survivors who are marked in this fashion is small, but 
such milliards of children are attacked every year that, 
on the old familiar principle, " if you throw plenty of 
mud some of it will stick," quite a serious number are 
more or less handicapped by these remainders. For 
instance, quite a noticeable percentage of cases of 
chronic eye troubles, particularly of the lids and con- 
junctiva, such as "granulated" lids, styes, ulcers of the 
cornea, date from an attack of measles or even whoop- 
ing-cough. Many cases of nasal catarrh or chronic 
throat trouble or bronchitis in children date from the 
same source. A large group of chronic discharges from 


the ear and perforations of the ear-drum are a direct 
after-result of scarlet fever; and the frequency with 
which this disease causes serious disturbances of the 
kidneys is almost a household word. Less definitely 
traceable, but even more serious in their entirety, are 
the large group of chronic depression of vigor, loss of 
appetite, various forms of indigestion and of bowel 
trouble, which are left behind after the visitation of 
one of these minor pests, particularly among the 
children of the poorer classes, who are unable to obtain 
the highly nutritious, appetizing, and delicately cooked 
foods which are so essential to the full recovery of the 
little invalids. 

One of the English commissions which was investigat- 
ing the alleged physical deterioration of city and town 
populations stumbled upon a singularly interesting and 
significant fact in this connection, while plotting the 
curves of the rate of growth of the children in a given 
district in Scotland during a series of years. They were 
struck with the fact that children born in certain years 
in the same families, neighborhoods, and presumably 
the same circumstances, grew more rapidly and had 
a lower death-rate than those born in other years ; and 
that, on the other hand, children born in other years 
fell almost as far below the normal in their rate of 
growth. The only factor which they found to coincide 
with these differences was that in the years in which 
those children who made the slowest growth were born 
there had been unusually heavy epidemics of children's 
diseases and a high mortality ; while, on the other hand, 
those years whose "crop" of children made the best 


growth had been unusually free from such epidemics 
and had a correspondingly low mortality, showing 
clearly that even the survivors of children's diseases 
were not only not benefited, but distinctly handicapped 
and set back in their growth by the energy, so to speak, 
wasted in resisting the onslaught. 

This brings us to an aspect of these diseases which 
from both a philosophic and a practical point of 
view is most interesting and profoundly significant; 
and that is the question with which we opened : Why 
is a disease a disease of childhood? The old, primi- 
tive view was as guileless and as simple as the age in 
which the diseases occurred. They were regarded not 
merely by the laity but by grave and reverend physi- 
cians of the Dark Ages as a sort of necessary vital 
crisis peculiar and appropriate to each particular age 
of life, a sort of sweating out and erupting of 
"peccant humors" of the blood, which must be got rid 
of or else the individual would not thrive. Incredible as 
it may seem, so far was this idea extended, that the 
great Arabian physician-philosopher, Rhazes, actually 
included smallpox in this group, as the last of the " crises 
of growth" which had to appear and have its way in 
young manhood or womanhood. Quaint little echoes 
of this simple faith still ring in the popular mind, as, 
for instance, in the widespread notion about the danger- 
ousness of doing anything to check the eruption in 
measles and cause it to "strike in." Any mother in 
Israel will tell you, the first time you propose a bath 
or a wet pack to reduce the temperature in measles, that 
if you so much as touch water to the skin of that child 


it will "drive the rash in" and cause it to die in con- 
vulsions. And, of course, one of the commonest of a 
physician's memories is the expression of relief from the 
mother cr aunt in any of these mild eruptive fevers, 
where the skin was well reddened and spotted : " Well, 
anyway, doctor, it is a splendid thing to get the rash 
so well out !" Until within the last ten or fifteen years 
it was no uncommon thing to hear the expression : 
" Well, I suppose we might just as well let Willie and 
Susie go on to school and get the measles and have done 
with it. It seems to be a real mild sort this time." 
Of course this view was scientifically shattered two or 
more decades ago by odr recognition of the infectious 
nature of these diseases, but practically its hold on the 
public mind constitutes one of the most serious and 
vital obstacles in the way of the health-officer when he 
endeavors to attack and break up an epidemic of 
measles, whooping-cough, or chicken-pox. 

It cannot be too strongly emphasized that, mild and 
in their immediate results trifling, as most of these 
"little diseases" are, they are genuine members of that 
class of pathologic poison-snakes, the germ-infections ; 
that when they bite, they bite to kill ; that two to five 
times in every hundred they do kill ; that, like all other 
infections, they are capable of inflicting serious and 
permanent damage upon the great vital organs, the 
heart, the kidneys, the liver, and the brain; and that 
they are the very jackals of diseases, tracing down and 
pointing out the prey to the lions that work in partner- 
ship with them. With whatever we may treat measles 
and whooping-cough, never treat them with contempt ! 


The next conception of the " whyness " of children's 
diseases was that as one star differs from another in 
glory, so does one germ differ from another in virulence ; 
that the germs of these particular diseases just happened 
to be from the beginning unusually mild and at the 
same time highly contagious, so that they remained 
permanently scattered about throughout the com- 
munity, and attacked each successive brood of new- 
born children as quickly as they could conveniently 
get at them. Being so mild and so comparatively 
seldom fatal, little or no alarm was excited by them and 
few efforts made to check their spread, so that they 
continued to flourish, generation after generation. 
Upon this theory the germs of measles, chicken-pox, 
whooping-cough, mumps, would be in something like 
the same class as the numerous species of bacteria and 
other germs that normally inhabit the human mouth, 
stomach, and intestines; for the most part, compara- 
tively harmless parasites, or what are technically now 
known as "symbiotes" (from two Greek words, bios, 
"life," and syn, "with"), a sort of little partners or 
non-paying boarders, for the most part harmless, but 
occasionally capable of making trouble. There are 
scores of species of such germs in our food-canals, some 
of which may be even slightly helpful in the process 
of digestion. Only a very small per cent of the bacilli 
of any sort in the world are harmful ; the vast major- 
ity are exceedingly helpful. 

There is evidently some truth in this view of chil- 
dren's diseases, especially so far as the reason for their 
steady persistence and undiminished spread is con- 


c rned, namely, the comparative carelessness and 
indifference with which they are regarded and treated. 
But some rather striking developments of recent years 
have raised grave doubts in our minds as to whether 
they were always the mild and inoffensive "house cats" 
that they pass for at present. These are the astonishing 
and almost incredible developments that occur when 
for the first time these mild and harmless " diseaselets " 
are introduced to a savage or half-civilized tribe. Like 
an Arabian Nights' transformation, our sleepy, purr- 
ing, but still able to scratch, "pussy cat" flashes out 
as a ravenous man-eating tiger, killing and maiming 
right and left. Measles harmless, tickly, snuffly, 
"measly" little measles kills from thirty to sixty 
per cent of whole villages and tribes of Indians and 
cripples half the remainder! 

My first direct experience with this feature of our 
" household pets " was on the Pacific Coast. All the old 
settlers told me of a dread pestilence which had pre- 
ceded the coming of the main wave of invading civiliza- 
tion, sweeping down the Columbia River. Not merely 
were whole clans and villages swept out of existence, 
but the valley was practically depopulated ; so that, 
as one of the old patriarchs grimly remarked, " It made 
it a heap easier to settle it up quietly." So swift and so 
fatal had been its onslaught that villages would be 
found deserted. The canoes were rotting on the river 
bank above high-water mark. The curtains of the 
lodges were flapped and blown into shreds. The wea- 
pons and garments of the dead lay about them, rusting 
and rotting. The salmon-nets were still standing in 


the river, worn to tatters and fringes by the current. 
Yet, from the best light that I was able to secure upon 
it, it appeared to have been nothing more than an 
epidemic of the measles, caught from the child of some 
pioneer or trapper and spreading like wildfire in the 
prairie grass. A little later I had an opportunity to 
see personally an epidemic of mumps in a group of 
Indians, and I have seldom seen fever patients, ill 
of any disease, who were more violently attacked and 
apparently more desperately ill than were sturdy young 
Indian boys attacked by this trifling malady. Their 
temperatures rose to one hundred and five or one hun- 
dred and six degrees, they became delirious, their faces 
were red and swollen, they ached in every limb, and 
the complications that occasionally follow mumps 
even in civilized patients were frequent and exceed- 
ingly severe. In like mariner, influenza will slay its 
hundreds in a tribe of less than a thousand members. 
Chicken-pox will become so virulent as to be mistaken 
for smallpox. Several of the epidemics of alleged small- 
pox that have occurred among Indians and other savage 
tribes are now known to have been only measles. At 
first, pathologists were inclined to receive these reports 
with some degree of skepticism, and to regard them 
either as travelers' tales, or as instances of exceptional 
and accidental virulence in that particular tribe, the 
high death-rate due to bad nursing or horrible methods 
of voodoo treatment. 

But from all over the world came ringing in the same 
story, not merely from scores of travelers, but also 
from army surgeons, medical missionaries, and medi- 


cal explorers, until it has now become a definitely estab- 
lished fact that the mild, trifling diseases of infancy, 
"colds" and influenzas of civilized races, leap to the 
proportions of a deadly pestilence when communicated 
to a savage tribe. Whether that tribe be the Eskimo 
of the Northern ice-sheet or the Terra del Fuegian 
of the Southern, the Hawaiian of the islands of the 
Pacific or the Aymaras of the Amazon, all fall like grain 
before the scythe under the attack of a malady which 
is little more than the proverbial " little 'oliday " of 
three days in bed to civilized man. Evidently civilized 
man has acquired a degree and kind of immunity that 
uncivilized man has not. Either the disease has grown 
milder or civilized man tougher with the ages. 

The probability is that both of these explanations 
are true. These diseases may originally have been 
comparatively severe and serious; but as generation 
after generation has been submitted to their attack, 
those who were most susceptible died or were so crip- 
pled as to be seriously handicapped in the race of life 
and have left fewer and less vigorous offspring. So 
that, by a gradual process of weeding out the more 
susceptible, the more resisting survived and became 
the resistant civilized races of to-day. 

On the other hand, any disease which kills its victim 
so quickly that it has not time to make sure of its trans- 
mission to another one before his death, will not have 
so many chances of survival as will a milder and more 
chronic disorder. Hence, the milder and less fatal 
strains of germs would stand the better chance of sur- 
vival. This, of course, is a very crude outline, but it 


probably represents something of the process by which 
almost all known diseases, except a few untamable 
hyenas, like the Black Death, the cholera, and small- 
pox, have gradually grown milder with civilization. 
If we escape the attack of these attenuated diseases 
of infancy until fifteen or sixteen years of age, we can 
usually defy them afterward; though occasionally an 
unusually virulent strain will attack an adult, with 
troublesome consequences. 

At all events, whatever explanation we may give, the 
consoling fact stands out clearly that civilized man is 
decidedly more resistant to these pests of civilization 
than is any half-civilized race, and there is good reason 
to believe that this is a typical instance of his compara- 
tive vigor and endurance all along the line. 

If this view of the original character and taming of 
these diseases be correct, it also accounts for the ex- 
traordinary and otherwise inexplicable cases where they 
suddenly assume the virulence of cholera, or yellow 
fever, and kill within forty-eight or ninety-six hours, 
not merely in children but also in adults. 

To group these three diseases together simply be- 
cause they all happen to occur in children would appear 
scarcely a rational principle of classification. Yet, 
practically, widely different as they are in their ultimate 
results and, probably, in their origin, they have so many 
points in common as to their method of spread, pre- 
vention, and general treatment, that what is said of one 
will with certain modifications apply to all. 

I said " probably " of widely different origin, because, 
by one of those strange paradoxes which so often con- 


front us in real life, though the infectiousness and the 
method of spread of all these diseases is as familiar as 
the alphabet and as firmly settled, the most careful 
study and innumerable researches have failed to 
identify positively the germ in any one of them. There 
are a number of "suspects" against which a great deal 
of circumstantial evidence exists: a streptococcus in 
scarlet fever, a bacillus in whooping-cough, and a pro- 
tozoan in measles; but none of these have been defi- 
nitely convicted. The principal reason for our failure 
is a very common one in bacteriological research, 
whose importance is not generally known, and that is, 
that there is not a single species of the lower animals 
that is subject to the diseases or can be inoculated with 
them. This unfortunate condition is the greatest bar- 
rier which can now exist to our discovery of the causa- 
tion of any disease. We were absolutely blocked, for in- 
stance, by it in smaHpox and syphilis until we discov- 
ered that our nearest blood relatives, the ape and the 
monkey, are susceptible to them ; and then the Cytoryctes 
Variolce and the Treponema pallida were discovered 
within comparatively a few months. Some lucky day, 
perhaps, we may stumble on the animal or bird which 
will take measles, scarlet fever, or whooping-cough, 
and then we will soon find out all about them. 

But, fortunately, our knowledge of these little dis- 
eases, like Mercutio's wound, is "not so deep as a well, 
nor so wide as a church door; but 't is enough" for all 
practical purposes. The general plan of treatment in all 
of them might be roughly summed up as, rest in bed 
in a well-ventilated room ; sponge-baths and packs for 


the fever; milk, eggs, bread, and fruit diet, with plenty 
of cool water to drink, either plain, or disguised as 
lemonade or "fizzy" mixtures; mild local antiseptic 
washes for nose and throat, and mild internal antisep- 
tics, with laxatives, for the bowels and kidneys. There 
is no known drug which is specific in anyone of them, 
though their course may be made milder and the patient 
more comfortable by the intelligent use of a variety 
of remedies, which assist nature in her fight against 
the toxin. Not knowing the precise cause, we have as 
yet no reliable antitoxin for any. 

Now very briefly as to the earmarks of each particu- 
lar member of this children's group. It may be said in 
advance that the " openings" of all of them (as chess- 
players call the first moves) are very much alike. All of 
them are apt to begin with a little redness and itching 
of the mucous membranes of the nose, the throat, and 
the eyes, with consequent snuffliiig and blinking and 
complaints of sore throat. These are followed, or in se- 
vere, swift cases may be preceded, by flushed cheeks, 
complaints of headache or heaviness in the head, fever, 
sometimes rising very quickly to from one hundred and 
four to one hundred and five degrees, backache, pains 
in the limbs, and, in very severe cases, vomiting. In 
fact, the symptoms are almost identical with those of an 
attack of that commonest of all acute infections, a 
bad cold, and probably for the same reason, namely, 
that the germs, whatever they may be, attack and 
enter the system by way of the nose and throat. 

One of the most difficult practical points about the 
beginning of this group of diseases is to distinguish 


them from one another, or from a common cold. The 
important thing to remember is that, theoretically im- 
portant as it may be to make this distinction, prac- 
tically it is n't necessary at all, as they should all be 
treated exactly alike in the beginning. The only vital 
thing is to recognize that you are dealing with an infec- 
tion of some sort, isolate promptly the little patient, 
put him to bed, and make your diagnosis later as the 
disease develops. Fortunately neither scarlet fever 
nor measles usually becomes acutely infectious until 
the rash appears, and as neither is particularly danger- 
ous to adults, especially to such as have had them 
already, a one-room quarantine is sufficient for the first 
few days of any of these diseases. We will lose nothing 
and gain enormously by adopting this routine plan in 
all cases of snuffling noses, sore throats, headache, 
and fever in children, for these are the early symptoms 
of all their febrile diseases, from colds to diphtheria ; all 
alike are infectious and all, even to the mildest, bene- 
fited by a few days of rest and seclusion. 

After this first general blare of defiance on the part 
of the system to the enemy, whoever he may be, the 
battle begins to take on its characteristic form accord- 
ing to the nature of the invader. We will take first the 
campaign of scarlet fever, since this is the swiftest and 
first to disclose itself. After the preliminary snuffles and 
headache have lasted for a few hours, the temperature 
usually begins to rise; and when it does, by leaps and 
bounds often reaching one hundred and four or one 
hundred and five degrees within twelve hours, the skin 
becomes dry and hot, the throat sore, the tongue 


parched, and the little patient drowsy and heavy-eyed. 
Within from twenty-four to forty-eight hours a bright 
red or pinkish rash appears, first on the neck and chest, 
and then rapidly spreading all over the surface of the 
body within another twenty-four hours. 

Meanwhile the throat becomes sore and swollen, 
ranging, according to the severity of the case, from a 
slight reddening and swelling to a furious ulcerative 
inflammation, with the formation of a thick membrane- 
like exudate, which sometimes is so severe as to raise a 
suspicion of possible diphtheria. The tongue becomes 
red and naked, with the papillae showing light against 
a red ground, so as to give rise to what has been known 
as "the strawberry tongue." The temperature is 
usually high, and the little patient when he drowses 
off to sleep is quite apt to become more or less delirious. 
In the vast majority of cases, after two to four days of 
this, the temperature goes down almost as swiftly as it 
came up, the rash begins to fade, the throat gets less 
sore, and the rebound toward recovery sets in. About 
this time the daily examination of the urine will begin 
to show traces of albumin, but this, under strict rest 
in bed and careful diet, will usually diminish and ulti- 
mately disappear. In the event of a relapse, however, 
or setback from any cause, the kidneys may become 
violently attacked, and a considerable per cent of the 
fatal cases die from suppression of the urine. After 
this crisis has occurred, however, in ninety-nine per 
cent of all cases it is comparatively plain sailing; the 
throat is still sore and troublesome, the skin itches and 
tickles, and the eyes smart, but the little patient steadily 


improves day by day. Anywhere from three to five days 
after the break in the fever the skin begins to get rough 
and scaly, and gradually peels off, until in some cases 
the entire coating of the body is shed, having been 
killed, as it were, by the violence of the eruption. These 
flakes and scales of the skin are exceedingly contagious, \ 
and no case should be regarded as fit to be released 
from isolation until every particle has been shed and 
got rid of. This constitutes one of the most tiresome 
and annoying periods of the disease, as complete shed- 
ding is seldom finished before two weeks, and some- 
times may last from Jhree to five. 

However, this long period of contagiousness has been 
found to be really a blessing in disguise, inasmuch as 
we now know that even more strikingly than in the 
other children's diseases it is the period of recovery that 
is the period of greatest danger in scarlet fever. Like the 
Parthians of Greek history it is most dangerous when 
in retreat. Keeping the child at rest for the greater 
part of the time, in bed or on a lounge, in a well- 
ventilated room, or later on a porch or terrace, for five 
weeks from the beginning of the disease, is well worth 
all the trouble and inconvenience that it causes, for 
the sake of the almost absolute protection it gives 
against dangerous and even fatal complications, par- 
ticularly of the kidneys, heart, or lungs. 

This is a fair description of what might be termed 
an average case of the disease. We also have the sadly 
familiar type described as the fulminant or, literally, 
" lightning-stroke" variety. The child goes down as if 
struck by an invisible hand ; vomiting is one of the first 


symptoms ; delirium follows within ten or twelve hours ; 
the eruption becomes not merely scarlet but purplish 
from hemorrhage under the skin, giving the name of 
" black" scarlet fever to this type. The throat becomes 
furiously swollen, the urine is absolutely suppressed, the 
child goes into convulsions, and dies within forty-eight 
hours from the beginning of the attack. Fortunately, 
this type is rare, but the important thing to remember 
is that it may develop in a child who caught the disease 
from one of the mildest of all possible cases! Hence 
every case should be treated with the strictest isolation, 
as if it were itself of the most malignant type. 

Naturally, the mortality of scarlet fever varies ac- 
cording to the type. Not only may it assume a malig- 
nant form in individual cases, but whole epidemics may 
be of this character, with a mortality of from twenty 
to thirty per cent. Generally speaking, however, the 
death-rate is about one in twelve, ranging from as low 
as one in twenty-five to as high as one in five. 

As in the case of diphtheria, the greatest danger 
and most powerful means of spread of the disease is 
through the mild, unrecognized cases, which are sup- 
posed to have nothing but a cold and are allowed to 
continue in school or play with other children. We 
have no antitoxin and no bacteriologic means of 
positive diagnosis. But one method will stop the spread 
and w r ithin ten or fifteen years exterminate every one 
of these infections isolate at once every child that 
shows symptoms of a cold, sore throat, or feverishness, 
both for its own sake and for that of the community ! 

In measles we have to deal with a much more harm- 


less and more nearly domesticated "beast of prey," 
but one of a prevalence to correspond. Though prob- 
ably (exact data being as yet lacking) not more than 
one-third of all individuals are attacked by scarlet 
fever, it would be safe to say that not more than one- 
third, and possibly not more than one-fifth, of us escape 
measles. Hence, though its mortality is scarcely one- 
fourth that of scarlet fever, it more than holds its own 
in the Herod class, as grimly shown by its total death- 
roll of over twelve thousand, compared with only a 
little over six thousand to the credit of scarlet fever. 

After the preliminary disturbances of snuffles, hot 
throat, headache, and feverishness, which it shares with 
all the other " little fevers," the first thing to mark off 
measles is usually that the itching and running at the 
nose and eyes become more prominent, the child begins 
to turn its face away from the light because it makes 
its eyes smart, and complains not so much of soreness 
as of a peppery, burning, itching sensation in its nose 
and throat. The tongue is coated, the stomach mildly 
upset; the little patient is more uncomfortable and 
fretful than seriously ill. This condition drags on, 
without apparently getting anywhere, for from two to 
four days, during which time it is often very difficult 
even for the most experienced physician to say posi- 
tively what the sufferer has. But about the fourth day 
a rash begins to appear, typically first upon the cheeks 
or forehead in the shape of little widely separated dull- 
red blotches. These grow larger and deeper in color, 
rising in the middle and spreading at their edges, so that 
shortly the whole skin becomes puffed and swollen and 


of a mottled, pinkish-purple color. If the child's lower 
lip be pulled down, little red spots will be seen scattered 
over the lining membrane of the mouth, showing that 
the eruption is not confined to the skin. Indeed, these 
Koplik's spots (as they are called, after their discoverer) 
in the mouth will often appear a day or more before 
the eruption upon the skin and give the first clew to the 
nature of the disease. These are significant, because 
they probably illustrate the process of eruption, or, at 
least, irritation, which is taking place, not merely upon 
the skin, but also upon the mucous membranes of the 
eyes, nose, and throat, the windpipe and the bronchial 
tubes, and which is the cause of the burning, running, 
and, later, occasional serious inflammatory symptoms 
in all these regions. 

When you look at the hot, angry-looking, swollen 
skin of the little victim of measles, the weeping eyes 
and running nose, and remember that this same sort 
of process is either going on or is likely to occur all 
over his entire lining, so to speak, from lungs to bowels, 
you can easily grasp how important it is to keep him 
absolutely at rest and protected from every possible 
risk in the way of chill, over-exertion, or injudicious 
feeding, until the whole process has completely sub- 
sided and been forgotten. Neglect of these precautions 
is the reason why so many cases of measles, on the least 
and most trifling exposure and overstrain during the 
two or three weeks following the disease, will blaze up 
into a fatal bronchitis or pneumonia. 

The rash takes about two or three days to get out, 
then it begins to fade and the skin to peel off in tiny, 


branny scales, so small and thin as to be almost invisi- 
ble unlike the huge flakes of scarlet fever. At the 
same time all the other symptoms recede. 

But, as in scarlet fever, all cases should be treated 
alike, by rest, sponging and packing for the fever, light 
diet with plenty of milk and fruit, and confinement to 
the room for at least ten days after the disappearance 
of the fever. The very mildest and most insignificant 
of attacks may be followed, through carelessness or 
exposure, by a fatal bronchitis. Indeed, in view of the 
distressing frequency with which our histories of tuber- 
culosis in children contain the words, " Came on after 
measles," it is highly' advisable to watch carefully 
every child as regards abundant feeding, avoidance 
of overwork or overstrain, and of all unnecessary 
exposure to infection, wind, or wet, for two months after 
an attack of measles instead of the customary two 
weeks. As the disease is acutely infectious, the little 
victim should be isolated for at least three weeks after 
the disappearance of the fever ; but this again, as in the 
case of scarlet fever, is emphatically a blessing in dis- 
guise from his point of view, as \vell as a protection to 
the rest of the community. 

Should the" little fever" prove to be whooping-cough, 
it will be later still in positively declaring its definite 
intentions. The cold or catarrhal stage will be much 
milder, the fever lower, the cough a trifle more marked, 
but will drag on for from a week to ten days before 
anything definite happens. Usually the child is sup- 
posed to be suffering with a slight cold, hence the pre- 
vailing impression that colds run into whooping-cough, 


if neglected. Then one day the child is suddenly seized 
with a coughing fit, consisting of from ten to fifteen 
short coughs in rapid succession of increasing intensity, 
until all the air seems literally pumped out of the lungs 
of the poor little patient; then, with a tremendous 
whoop, the youngster gets his breath again and the 
diagnosis is made. This distressing performance may 
occur only four or five times a day, or it may be re- 
peated every half-hour or so. So violent is the paroxysm 
that the eyes of the child protrude, it becomes literally 
black in the face, and runs to its mother or nurse, or 
clutches a chair, to keep from falling. 

As the same great nerves which supply the lungs 
supply the stomach, the irritation frequently " radiates," 
or spills over, from one division of it to the other, and 
the coughing fit is frequently followed by vomiting. 
Unexpectedly enough this may often become the most 
serious practical symptom of the disease, inasmuch as 
the stomach is emptied so frequently that the poor 
little victim is unable to retain any nourishment long 
enough to absorb it, and may waste away frightfully, 
and even literally starve to death, or have its resisting 
power so greatly lowered that an attack of bronchial 
trouble or bowel disturbance will prove rapidly fatal. 

So serious are the disturbances of the circulation all 
over the body by these spasmodic suffocation-fits, that 
rupture of small blood-vessels may occur in the eyes, 
the brain, in the lungs, and on the surface of the skin. 
The heart becomes distended, and if originally weak- 
ened may be seriously dilated or overstrained ; the 
lungs become congested and inflamed, and any of the 


numerous accidental germs which may be present will 
set up a broncho-pneumonia, which is the commonest 
cause of death in this disease, as in measles. 

Strangely enough, while, as we do not positively know 
the germ, and hence cannot state definitely either the 
cause or the principal seat of the trouble, it is not gen- 
erally believed that the condition of the lungs or the 
throat has much to do with the cough. 

At all events, it is perfectly idle to treat the disease 
with cough mixtures or expectorants. The view toward 
which the majority of intelligent observers are inclined 
is that whooping-cough is an infection, the germ or 
toxin of which attacks the nervous system, and par- 
ticularly the great "lung-stomach" (pneumogastric) 
nerve. At all events, the only remedies which appear 
to have any effect upon the disease are, in the early 
stages, mild local antiseptics in the nose and throat, 
and later those which diminish the irritability of the 
nerves without upsetting the appetite or depressing the 
general vigor. The disease is, for all its mildness, 
one of the most obstinate known. 

A small percentage of cases run a violent course, 
in spite of the most intelligent and anxious care, both 
medical and household ; but the vast majority of such 
complications as occur are either caused by careless- 
ness or become serious only if neglected. Treating 
all children with whooping-cough as emphatically sick 
children, entitled to every care and excuse from exer- 
tion, every exemption and privilege that can be given 
them until the last whoop has been whooped, would 
prevent at least two-thirds of the almost ten thousand 


deaths from whooping-cough that yearly disgrace the 
United States. 

To sum up in fine: intelligent, effective isolation 
of all cases, the mild no less than the severe, would 
stamp out these Herods of the twentieth century within 
ten years. In the meantime, six weeks' sick-leave, with 
all the privileges and care appertaining thereto, will 
rob them of two-thirds of their terrors. 



WE were not made all at once, nor do we go to 
pieces all at once, like the "one-boss shay." 
This is largely because we are not all of the same age, 
clear through. Some parts of us are older than other 
parts. We have always felt a difficulty, not to say a deli- 
cacy, in determining the age of a given member of the 
human species especially of the gentler sex. Now we 
know ihe reason of it. From the biologic point of view, 
we are not an individual, but a colony ; not a monarchy, 
but a confederacy of organ-states, each with its millions 
of cell-citizens. It is not merely editors and crowned 
heads who have a biologic right to say "We." There- 
fore, obviously, any statement that we make as to our 
age can be only in the nature of an average struck be- 
tween the ages of our heart, lungs, liver, stomach; 
and as these vary in ancientness by thousands of years, 
the average must be both vague and misleading. The 
only reason why there is a mystery about a woman's 
age is that she is so intensely human and natural. 
The only statement as to our age that the facts would 
strictly justify us in making must partake of the vague- 
ness of Mr. A. Ward's famous confession that he was 
" between twenty-three summers." 

As we individually climb our own family-tree, from 
the first, one-celled droplet of animal jelly up, none of 


our organs is older than we are, but a number of them 
are younger. The appendix is one of these. Now, by 
some curious coincidence, explain it as we may, some 
of our oldest organs are youngest, in the sense of most 
vigorous, elastic, and resisting, while some of our 
youngest are oldest, in the sense of decrepit, feeble, 
and unstable. It is perhaps only natural that an organ 
like the stomach, for instance, which has a record of 
honorable service and active duty millions of years 
long, should be better poised, more reliable, and more 
resourceful than one which, like the lung or the appen- 
dix, has, as it were, a "character" of only about one- 
tenth of that length. However this may be, the curious 
fact confronts us that scattered about through the 
body are structures and fragments, the remains of 
organs which at one time in our ancestral career were, 
under the then existing circumstances, of utility and 
value, but have now become mere survivals, remnants, 
in the language of the day, " back numbers." Some 
of these have still a certain degree of utility, though 
diminished and still diminishing in size and functional 
importance, like our third molars or "wisdom" teeth, 
our fifth or "little" toes, our gall-bladder, our coccyx 
or tail-bone, the hair-glands scattered all over the now 
practically hairless surface of our bodies, and our once 
movable ears, which can no longer be "pricked," or 
laid back. These, though of far less utility and import- 
ance than they obviously were at one time, still earn 
their salt, and, though all capable of causing us con- 
siderable annoyance on slight provocation, seldom 
give rise to serious trouble or inconvenience. There are, 


however, a few of these " oversights " which are of little 
or no known utility, and yet which, either by their 
structure or situation, may become the starting-point 
of serious trouble. 

The best known members of this small group are the 
openings through the abdominal wall, which, originally 
placed at the strongest and safest position in the quad- 
rupedal attitude, are now, in the erect attitude, at the 
weakest and most dangerous, and furnish opportunity 
for those serious and sometimes fatal escapes of por- 
tions of the intestines which we call hernia ; the tonsils ; 
and our friend the avpendix vermiformis. 

For once its name expresses it exactly. It is an 
" appendix," an afterthought ; and it is " vermiformis" 
a worm-like creature, and, like the worm, will some- 
times turn when trodden on. Its worm-likeness is sig- 
nificant in another sense also, in that it is this very di- 
minutiveness in size the coils into which it is thrown, 
the spongy thickness of its walls, and the readiness 
with which its calibre or its circulation is blocked 
that is the fundamental cause of its tendency to disease. 

The cause of appendicitis is the appendix. 

" Despise not the day of small things" is good patho- 
logy as well as Scripture. Here we have a little, worm- 
shaped tag, or side branch, of the food-tube, barely 
three or four inches long, of about the diameter of a 
small quill and of a calibre that will barely admit an 
ordinary knitting needle. And yet we speak of it with 
bated breath. When we remember that this little, 
twisted, blind tube opens directly out of one of the 
largest pouches of the intestines (the caecum) , and that it 


is easy for anything that may be present in the large 
pouch food, irritating fragments of waste matter, 
or bacteria to find its way into this fatal little trap, 
but very difficult to find the way out again, we can form 
some idea of what a literal death-trap it may become. 

How did such a useless and dangerous structure ever 
come to develop in a body in which for the most part 
there is mutual helpfulness, utility, and perfect smooth- 
ness of working through all the great machine ? To 
attempt to answer this would carry us very far back 
into ancient history. But to make such backward 
search is absolutely the only means of reaching an an- 

"But," some one will object, "how perfectly irra- 
tional, not to say absurd, to propose to go back hun- 
dreds of thousands of years into ancient history, to 
account for a disease which has been discovered 
according to some, invented within the past twenty- 
five years!" 

Appendicitis is a mark, not a result, of a high grade of 
civilization. To have had an operation for it is one of 
the insignia of modern rank and culture. Our new bio- 
logic aristocracy, the "Appendix-Free," look down 
with gentle disdain upon their appendiciferous fellows 
who still bear in their bodies this troublesome mark 
of their lowly origin. In short, the general impression 
prevails that appendicitis is a new disease, a disease 
which has become common, or perhaps occurred at all, 
only within the last quarter of a century, and which 
therefore with the usual flying leap of popular logic 
is a serious menace to our future, if it keeps on in- 


creasing in frequency and ferocity at anything like the 
same rate which it has apparently shown for the past 
fifteen years. 

As this feeling of apprehension is in many minds 
quite genuine, it may be well to say briefly, before pro- 
ceeding further, first, that, if there be any disease 
which absolutely and almost exclusively depends upon 
definite peculiarities of structure, it is appendicitis, 
and that these structural peculiarities of this tiny, 
cramped tag of the food-canal have existed from the 
earliest infancy of the race. So it is almost unthinkable 
that man should not Jiave been subject to fatal disturb- 
ances of this organ from the very earliest times. On 
the post-mortem table, the appendix of the lowest sav- 
age is the same useless, shriveled, and inflammable 
worm as that of the most highly civilized Aryan, though 
perhaps an inch or so longer. Secondly, there is abso- 
lutely no adequate proof that appendicitis is increasing 
in frequency among civilized races It is only about 
twenty-five years ago that it was first definitely de- 
scribed, and barely fifteen that the profession began at 
all generally to recognize it. 

But all of us whose memory extends backward a 
quarter of a century can clearly recall that, while we did 
not see any cases of "appendicitis," we saw dozens 
of cases of " acute enteritis," " idiopathic (self-caused) 
peritonitis," "acute inflammation of the bowels," 
" acute obstruction of the bowels," of which patients 
died both painfully and promptly, and which we now 
know were really appendicitis. 

In short, from a careful study of all the data, includ- 


ing the claims so frequently made of freedom from ap- 
pendicitis on the part of Oriental races, colored races, 
less civilized tribes, vegetarians, and others, we are 
tending toward the conclusion that the percentage of 
appendicitis in a given community is simply the per- 
centage of its recognition, in other words, of the in- 
telligence and alertness, first of its physicians, and then 
of its laity. As an illustration, my friend Dr. Bloodgood 
kindly had the statistics of the surgical patients treated 
in the great Johns Hopkins Hospital at Baltimore in- 
vestigated for me, and found almost precisely the same 
percentage of cases of appendicitis among colored pa- 
tients as among white patients. 

The earlier impression, first among physicians 
and now in the laity, that appendicitis is an almost 
invariably fatal disease, is not well founded, and we 
now know that a large percentage of cases recover, 
at least from the first attack ; so that it is quite possible 
for from half to two-thirds of the cases of appendicitis 
actually occurring in a given community to escape 
recognition, unless promptly reported, carefully ex- 
amined, and accurately diagnosed. Thirdly, in spite 
of the remarkable notoriety which the disease has at- 
tained, the general dread of its occurrence, which 
has been recently well expressed in a statement that 
everybody either has had it, or expects to have it, or 
knows somebody who has had it, the actual percent- 
age of occurrence of grave appendicitis is small. In 
the United States census of 1900, which was the first 
census in which it was recognized as a separate cause 
of death, it was responsible for only 5000 deaths in the 


entire United States for the ten years preceding, or 
about one death in two hundred. This rate is corrobo- 
rated by the data, now reaching into thousands, from 
the post-mortem rooms of our great hospitals, which 
report an average of between a half and one per cent. 
A disease which, in spite of the widespread terror of it, 
kills only one in two hundred of those who actually 
die or about one in every ten thousand of our popu- 
lation is certainly nothing to become seriously excited 
over from a racial point of view. 

While appendicitis is one of the "realest" and most 
substantial of diseases^ and, in its serious form, highly 
dangerous to life, there can be little doubt that there 
has come, first of all, a state of mind almost approach- 
ing panic in regard to it; and, second, a preference for 
it as a diagnosis, as so much more distingue than such 
plebeian names as " colic," " indigestion," " enteritis," 
or the plain old Saxon " belly-ache," which has reached 
almost the proportions of a fad. It is certain that 
nowadays physicians have almost as frequently to re- 
fuse to operate on those who are clamoring for the 
distinction, as to urge a needed operation upon those 
unwilling to submit to it. 

The satirical proposal that a "closed season" should 
be established by law for appendicitis as for game birds, 
during which none might be taken, would apply almost 
as often to the laity as to the profession, even the sur- 
gical half. 

Since the chief cause of appendicitis is the appendix, 
the first question for disposal is, How did the appendix 
become an appendix? To this biology can render a 


fairly satisfactory answer. It is the remains of one of 
Mother Nature's experiments with her 'prentice hand 
upon the mammalian food-tube. As is now generally 
known, the food-canal in animals was originally a 
comparatively straight tube, running the length of the 
body from mouth to anus. It early distends into a 
moderate pouch, about a third of the way down from 
the mouth, forming a stomach, or storage and churning- 
place for the food. Below this, it lengthens into coils 
(the so-called small intestine), which, as the body be- 
comes more complex, increase in number and length 
until they reach four to ten times the length of the body. 
Later, the lower third of the tube distends and saccu- 
lates out into a so-called large intestine, in which the 
last remnants of nutritive material and of moisture are 
extracted from the food-residues before they are dis- 
charged from the body. Just at the junction of this 
large intestine with the small intestine, nature took 
it into her head to develop a second pouch, a sort of 
copy of the stomach. This pouch, from the fact that it 
ends in a blind sac, is known as the ccecum (or " blind " 
pouch), and is apparently simply a means of delaying 
the passage of the foodstuffs until all the nutriment and 
moisture have been absorbed out of them for the ser- 
vice of the body. Naturally, it has developed to the 
largest degree and size in those animals which have 
lived upon the bulkiest and grassiest of foods, the so- 
called Herbivora, or grass-eaters. In the Carnivora, 
or flesh-eaters, it is usually small, and in one family, 
the bears, entirely absent. This pouch is no mere figure 
of speech, as may be gathered from the fact that in 


certain of the rodent Herbivora, like the common 
guinea-pig, it may have a capacity equal to all of the 
rest of the alimentary canal, and in the horse it will 
hold something like four times as much as the stomach. 
Oddly enough, among the grass-eaters, for some reason 
which we do not understand, it appears to occur in a 
sort of inverse proportion to the stomach ; those which 
have large, sacculate, pouched stomachs, like the cow, 
sheep, and the ruminants generally, having smaller 
cceca. In other Herbivora with small stomachs, like 
the rabbit and the horse, it develops greater size. 

Our primitive ancestors were mixed feeders, and, 
though probably more largely herbivorous than we are 
to-day, had a medium-sized caecum, and maintained 
it up to the point at which the anthropoid apes began 
to branch off from our family-tree. But at about this 
point, for some reason, possibly connected with the 
increasing variety and improved quality and concen- 
tration of the food, due to greater intelligence and 
ability to obtain it, this large ccecum became unneces- 
sary, and began to shrivel. 

Here, however, is where nature makes her first after- 
thought mistake. Instead of allowing this pouch to con- 
tract and shrivel uniformly throughout its entire length, 
she allowed the farther (or distal) two-thirds of it 
to shrivel down at a much faster rate than the central 
(or proximal) third ; so that the once evenly distended 
sausage-shaped pouch, about six to eight inches long 
and two inches in diameter, has become distorted down 
into a narrow, contracted end portion, about a quarter 
of an inch in diameter, and a distended first portion, 


for all the world like a corncob pipe with a crooked 
stem and an unusually large bowl. And behold the 
modern appendix vermiformis, with all its fatal possi- 
bilities ! 

If we want something distinctly human to be proud 
of, we may take the appendix, for man is the only 
animal that has this in its perfection. A somewhat 
similarly shriveled last four inches of the caecum is found 
in the anthropoid apes and in the wombat, a burrowing 
marsupial of Australia. In some of the monkeys, and 
in certain rodents like the guinea-pig, a curious imi- 
tation appendix is found, which consists simply of 
a contracted last four or five inches of the caecum, 
which, however, on distention with air, is found to 
relax and expand until of the same size as the rest of 
the gut. 

The most strikingly and distinctly human thing about 
us is not our brain, but our appendix. And, while 
recognizing its power for mischief, it is only fair to 
remember that it is an incident and a mark of progress, 
of difficulties overcome, of dangers survived. In all 
probability, it was our change to a more carnivorous 
diet, and consequently predatory habits, which ena- 
bled our ancestors to step out from the ruck of the 
"Bandar-Log," the Monkey Peoples. An increase in 
carnivorousness must have been a powerful help to our 
survival, both by widening our range of diet, so that 
we could live and thrive on anything and everything 
we could get our hands on, and by inspiring greater re- 
spect in the bosoms of our enemies. Let us therefore 
respect the appendix as a mark and sign of historic 


progress and triumph, even while recognizing to the 
full its unfortunate capabilities for mischief. 

But what has this ancient history to do with us in 
the twentieth century? Much in every way. First, 
because it furnishes the physical basis of our troubles ; 
and second, and most important, because, like other 
history, it is not merely repeating itself, but continuing. 
This process of shriveling on the part of the appendix 
is not ancient history at all, but exceedingly modern ; 
indeed, it is still going on in our bodies, unless we are 
over sixty-five years of age. 

In the first place, we have actually passed through 
two-thirds of this process in our own individual experi- 

At the first appearance of the ccecum, or blind pouch, 
in our prenatal life, it is of the same calibre as the rest 
of the intestine, and of uniform size from base to tip. 
About three weeks later the tip begins to shrivel, and 
from this on the process steadily continues, until at 
birth it has contracted to about one-fifteenth of the bulk 
of the ccecum. But the process does n't stop here, 
though its progress is slower. By about the fifth year 
of life the stem of the cseco-appendix pipe has dimin- 
ished to about one- thirtieth of the size of the bowl, 
which is the proportion that it maintains practically 
throughout the rest of adult life. For a long time we 
concluded that the process was here finished, and 
that the appendix underwent no further spontaneous 
changes during life; but, after appendicitis became 
clearly recognized, a more careful study was made of 
the condition of the appendix in bodies coming to the 


post-mortem table, dead of other diseases, at all ages 
of life. This quickly revealed an extraordinary and 
most significant fact, that, while the appendix was 
no longer decreasing in apparent size, its internal capa- 
city or calibre was still diminishing, and at such a rate 
that by the thirty-fifth year it had contracted down 
so as to become cut off from the cavity of the caecum 
in about twenty-five to thirty per cent of all individuals. 
By the forty-fifth year, according to the anatomist 
Ribbert (who has made the most extensive study of the 
subject), nearly fifty per cent of all appendices are 
found to be cut off, and by the sixty-fifth year nearly 
seventy per cent. 

This explains at once why appendicitis is so emphati- 
cally a disease of young life, the largest number of cases 
occurring before the twenty-fifth year (fifty per cent 
of all cases occur between ten and thirty years of age) , 
and becoming distinctly rarer after the thirty-fifth, 
only about twenty per cent occurring after this age. 
As soon as the cavity of the appendix is cut off from 
that of the intestine, it is of course obvious that infec- 
tious or other irritating materials can no longer enter 
its cavity to cause trouble, although, of course, it is 
still subject to accidents due to kinks, or twists, or 
interference with its blood-supply ; but these are not so 
dangerous, providing there be no infectious germs 

Here, then, we have a clear and adequate physical 
basis for appendicitis. A small, twisted, shriveling spur 
or side twig of the intestine, opening from a point which 
has become a kind of settling basin in the food-tube, 


its mouth gaping, as it were, to admit any poisonous 
or irritating food, infectious materials, disease-germs, 
the ordinary bacteria which swarm in the alimentary 
canal, or irritating foreign bodies, like particles of dirt, 
sand, hairs, fragments of bone, pins, etc., which may 
have been accidentally swallowed. Once these irritat- 
ing and infectious materials have entered it, spasm of 
its muscular coat is promptly set up, their escape is 
blocked, and a violent inflammation easily follows, 
which may end in rupture, perforation, or gangrene. 

Not only may any infection which is sweeping along 
the alimentary canal, thrown off and resisted by the 
vigorous, full-sized, well-fed intestine, find a point 
of lowered resistance and an easy victim for its attack 
in the appendix, but there is now much evidence to 
indicate that the ordinary bacteria which inhabit the 
alimentary canal, particularly that first cousin of the 
typhoid bacillus, the colon bacillus, when once trapped 
in this cul-de-sac, may quickly acquire dangerous 
powers and set up an acute inflammation. It is not 
necessary to suppose that any particular germ or infec- 
tion causes appendicitis. Any one which passes through, 
or attacks, the alimentary canal is quite capable of it, 
and probably does cause its share of the attacks. 

Numerous attempts have been made to show that 
appendicitis is particularly likely to follow typhoid 
fever, rheumatism, influenza, tonsilitis, and half a 
dozen other infectious or inflammatory processes. 
But about all that has been demonstrated is that it may 
follow any of them, though in none with sufficient fre- 
quency or constancy to enable it to be regarded as 


one of the chief or even one of the important causes 
of the disease. 

One dread, however, we may relieve our anxious 
souls of, and that is the famous grape-seed or cherry- 
stone terror. To use a Hibernianism, one of our most 
positive conclusions in regard to the cause of appendi- 
citis is a negative one : that it is not chiefly, or indeed 
frequently, due to the presence of foreign bodies. This 
was a most natural conclusion in the early days of the 
disease, since, given a tiny blind pouch with a con- 
stricted opening gaping upon the cavity of the food- 
canal, nothing could be more natural than to suppose 
that small irritating food remnants or foreign bodies, 
slipping into it and becoming lodged, would block 
it and give rise to serious inflammation. And, more- 
over, this a priori expectation was apparently con- 
firmed by the discovery, in many appendices removed 
by operation, of small oval or rounded masses, closely 
resembling the seed of some vegetable or fruit. Where- 
upon anxious mothers promptly proceeded to order 
their children to "spit out," with even more religious 
care than formerly, every grape-seed and cherry-stone. 
The increased use of fresh and preserved fruits was 
actually gravely cited, particularly by our Continental 
brethren, as one of the causes of this new American 
disease. Barely ten years ago I was spending the sum- 
mer in the Adirondacks, and was bitterly reproached 
by the host of one of the Lake hotels, because the pro- 
fession had so terrified the public about the dangers of 
appendicitis from fruit-seeds that he was utterly unable 
to serve upon his tables a large stock of delicious pre- 


served and canned raspberries, blackberries, and grapes 
which he had put up the previous years. "Why," 
he said, " more than half the people that come up here 
will no more eat them than they would poison, for fear 
that some of the seeds will give 'em appendicitis." 
This dread, however, has been deprived of all rational 
basis, first, by finding that many inflamed appendices 
removed, after the operation became more common, 
contained no foreign body whatever; secondly, that 
many perfectly healthy appendices examined on the 
post-mortem table, death being due to other diseases, 
contain these apparently foreign bodies; and thirdly, 
that when these "foreign bodies" were cut into, they 
were found to be not seeds or pits of any description, 
but hardened and, in some cases, partially calcareous 
masses of the faeces. 

We are in a nearly similar position in regard to the 
third alleged cause of appendicitis, and that is food. 
Many are the accusations which have been made in this 
field. On the one hand, meat and animal foods gen- 
erally have been denounced, on account of their sup- 
posed "heating" or "uric-acid-forming" properties; 
while on the other, vegetables and fruits have been 
equally hotly incriminated, on account of their seeds, 
fibres, husks, and irritating substances, and the danger 
of their being contaminated by bacteria and other par- 
asites freifl the soil. These charges appear to have little 
adequate foundation, and, so far as we are in a posi- 
tion now to judge, the only way a food can give, or be 
accessory to, appendicitis is by its being taken in such 
excessive amounts as to set up fermentive or putrefac- 


tive changes in the alimentary canal, or by its being 
in an unsound, decaying, or actually diseased condition. 
Any amounts or quality of food which are capable 
of giving rise to an attack of acute indigestion may 
secondarily lead to an attack of appendicitis. The only 
single article of diet whose ingestion is declared by 
Osier to be rather frequently followed by an attack 
of appendicitis is the peanut. 

Therefore, the best thing to do in the way of taking 
precautions against the occurrence of appendicitis is, 
in the language of the day, to " forget it" as completely 
as possible, reassuring ourselves that, in spite of its 
extraordinary notoriety and popularity, it is a com- 
paratively rare disease in its fatal form, responsible 
for not more than one-half of one per cent of the 
deaths, and that the older we grow, the better become 
our chances of escaping it. 

Whatever we may have decided in regard to our 
brains, by the time we reach fifty, we may feel reason- 
ably sure we've no appendix. 

But the question will at once arise, if the appendix 
be so tiny in size, so insignificant in capacity, and so 
devoid of useful function, what is the use of disturbing 
ourselves over the question of what may become of it ? 
If it is going to decay and drop off, why not permit it to 
do so, with the philosophic indifference with which 
we would sacrifice the tip of our little fingers in a plan- 
ing-mill ? Here, however, is just the rub, and the fact 
that gives to appendicitis all its terrors, and to the 
question of what to do in each particular case its 
difficulties and perplexities. 


The appendix does not, unfortunately, hang out 
from the surface of the body, where it could peacefully 
decay and drop off without prejudice to the rest of the 
body, or be quickly lopped off in the event of its giving 
trouble. On the contrary, it projects its stubby and 
insignificant length right into the midst of the most 
delicate and susceptible cavity of the body, the general 
cavity of the abdomen, or peritoneum. The thin, sensi- 
tive sheet of peritoneum which lines this cavity covers 
every fold and part of the food-tube, from the stomach 
down to the rectum. And when once infection or inflam- 
mation has occurred at any point in it, there is nothing to 
prevent its spreading like a prairie fire, all over the en- 
tire abdominal cavity from diaphragm to pelvis. If this 
wretched little remnant were a coil of explosive fuse 
within the brain-cavity itself, which any jar might set 
off, it could hardly be richer in possibilities of danger. 

A redeeming feature of appendicitis is that the ap- 
pendix lies so to speak in a corner, or wide- 
mouthed pouch, of the great peritoneal cavity; and if 
the inflammation set up in it can be "walled off" from 
the rest of the peritoneal cavity, and limited strictly 
to this little corner or pouch, all will be well. This is 
what occurs in those cases of severe appendicitis which 
spontaneously recover. If, however, this disturbance 
bursts its barriers, and lights up an inflammation of the 
entire peritoneal cavity, then the result is likely to be 
a fatal one. Just how far nature can be trusted in each 
particular case to limit and stamp out the process in this 
manner is the core of the problem that confronts us, 
as attending physicians. 


In the majority of cases, fortunately, the peritoneal 
fire brigade acts promptly, pours out a wall of exudate, 
and locks up the appendix in a living prison, to fight 
out its own battles and sink or swim by itself. But un- 
fortunately, in a minority of cases, by a wretched sort 
of "senatorial courtesy" which exists in the body, the 
appendix is given its ancestral or traditional rights and 
allowed to inflict its petty troubles upon the entire ab- 
dominal cavity, and include the body in its downfall. 

Lastly come the two most pertinent and appealing 
questions : 

What is the outlook for me if I should develop 
appendicitis ? And what is to be done ? 

In regard to the first of these, it is safe to say that 
our answer is much less alarming than it was in the 
earlier stage of our knowledge. Naturally enough, in 
the beginning, only the severest and most unmistak- 
able forms of the disease and those which showed no 
tendency to localization, were recognized, or at least 
came under the eye of the surgeon ; and as a large per- 
centage of these resulted fatally, the conclusion was 
reached, both in the medical profession and by the 
laity, that appendicitis was an exceedingly dangerous 
'disease, with a high fatality in all cases. As, however, 
physicians became more expert in the recognition of 
the disease, it was discovered to be vastly more com- 
mon, while side by side came the consoling knowledge 
that a considerable percentage of cases got well of 
themselves, in the sense of the inflammation being 
limited to the lower right-hand corner of the abdom- 
inal cavity, though, of course, with the possibility of 


leaving a smouldering fuse which might light up an- 
other explosion under any stress in future. 

Further, as the attention of the post-mortem inves- 
tigators at our large hospitals was directed to the sub- 
ject, it was found that a very considerable percentage 
of all bodies, ranging from twenty to according 
to some estimates as high as sixty per cent, showed 
changes in the appendix and its neighborhood which 
were believed to be due to old inflammations ; so that, 
while it is possible to speak only with great caution 
and reserve, the balance of opinion among clinicians 
and pathologists of wi^e experience and the more con- 
servative surgeons appears to be that from one-half to 
two-thirds of all cases of appendicitis will recover of 
themselves, in the sense of subsiding more or less 
permanently, without causing death. 

On the other hand, it must be remembered that the 
appendix is an organ which, so far as any evidence has 
been adduced, is entirely without useful function; 
that it is in process of shriveling and disappearance, 
if left entirely alone, and that the best result which can 
be expected from a self-cured attack of appendicitis 
is the destruction of the appendix and its elimination 
as a further possible cause of mischief. By avoiding 
an operation in appendicitis, we may be practically 
certain that we save nothing that is worth saving 
except the fee. Moreover, even though only from 
one-fourth to one-third of all cases develop serious 
complications, you never can be quite sure in which 
division your particular case will fall. 

The situation is in fact a little bit like one related 


in the experience of Edison, the inventor. The trustees 
of a church in a neighboring town had just completed 
a beautiful new church building with a high spire, pro- 
jecting far above any other building in the town. When 
it was nearing completion, the question arose, should 
they put on a lightning-rod. The great church itself 
had strained their financial resources, and one party 
in the board were of the opinion that they should avoid 
this unnecessary expense, supporting their economic 
attitude by the argument that, to put on a lightning- 
rod, would argue a lack of trust in Providence. Finally, 
after much debate, it was decided, as the great elec- 
trician was readily accessible, to submit the question 
to him. Mr. Edison listened gravely to the arguments 
presented, pro and con. 

" What is the height of the building, gentlemen ? " 

The number of feet was given. 

"How much is that above that of any surrounding 

The data were supplied. 

"It is a church, you say?" 

" Yes." 

" Well," said the great man, " on the whole, I should 
advise you to put on a lightning-rod. Providence is apt 
to be, at times, a trifle absent-minded." 

The chances are in favor of your recovery, but 
put on a lightning-rod, in the shape of the best and 
most competent doctor you know, and be guided en- 
tirely by his opinion. An attack of appendicitis is like 
shooting the Grand Lachine Rapids. Probably you 
will come through all right; but there is always the 


possibility of landing at a moment's notice on the rocks 
or in the whirlpools. With a good pilot your risk 
does n't exceed a fraction of one per cent. And fortu- 
nately this condition has been not merety theoretically 
but practically reached already; for the later series 
of case-groups of appendicitis treated in this intelligent 
way by cooperation between the physician and surgeon 
from the start, with prompt interference in those cases 
which to the practiced eye show signs of making 
trouble, has reduced the actual recorded mortality of 
the disease to between two and five per cent. Even 
of those cases which come to operation now, the death- 
rate has been reduced as low as five per cent, in series 
of from 400 to 600 successive operations. When we 
contrast this with the first results of operation, when 
the cases as a rule were seen too late for the best time 
of interference, and from twenty per cent to thirty per 
cent died ; and with the intermediate stage, when sur- 
geons as a rule were inclined to advise operation at the 
earliest possible moment that the disease could be 
recognized, and from ten per cent to fifteen per cent 
died, we can see how steady the improvement has been, 
and how encouraging the outlook is for the future. 

Cases which have weathered one attack of appendi- 
citis are of course by no means free from the risk of 
another. Indeed, at one time it was believed that a 
recurrence was almost certain to occur. Later investi- 
gations, based upon larger numbers of cases, now 
running up into the thousands, give the reassuring 
result that though this danger is a real one, it is not so 
great as it was at one time supposed, as the average 


number in whom a second attack occurs appears to be 
about twenty per cent. This, however, is a large enough 
risk to be worthy of serious consideration ; and in view 
of the fact that the mortality of operations done be- 
tween attacks is less than one per cent, it is generally 
the feeling of the profession that, where there is any 
appreciable soreness, or tenderness, or liability to 
attacks of pain in the right iliac region, in an individual 
who has had one attack of appendicitis, the really con- 
servative and prudent procedure is to have the source 
of the trouble removed once and for all. 

The four principal symptoms of appendicitis are: 
pain, which is usually felt most keenly somewhere be- 
tween the umbilicus and the right groin, though this 
is by no means invariable; tenderness in that same 
region upon pressure; rigidity of the muscles of the 
abdominal wall on the right side; and temperature, 
or fever. 

No matter how much and how variegated pain you 
may have in the abdomen, or how high your tempera- 
ture may run, if you are not distinctly sore on firm 
pressure down in this right lower or southwest quad- 
rant of the abdomen, but be careful not to press too 
hard, it is n't safe, you may feel fairly sure that you 
have n't got appendicitis. If you are, you may still not 
have it, but you 'd better send for the doctor, to be sure. 



MALARIA has probably killed more human be- 
ings than all the wars that have ever devastated 
the globe. Some day the epic of medicine will be writ- 
ten, and will show what a large and unexpected part it 
has played in the progress of civilization. Valuable and 
essential to that progress as were the classic great dis- 
coveries of fire, ships, wheeled carriages, steam, 
gunpowder, and electricity, they are almost paralleled 
by the victories of sanitary science and medicine in 
the cure and prevention of that greatest disrupter of 
the social organism disease. No sooner does the 
primitive human hive reach that degree of density 
which is the one indispensable condition of civiliza- 
tion, than it is apt to breed a pestilence which will 
decimate and even scatter it. Smallpox, cholera, and 
bubonic plague have bkzed up at intervals in the 
centres of greatest congestion, to scourge and shatter 
the civilization that has bred them. No civilization 
could long make headway while it incurred the dangers 
from its own dirtiness; and to-day the most massive 
and imposing remains of past and gone empires are 
their aqueducts, their sewers, and their public baths. 
What chance has a community of building up a steady 
and efficient working force, or even an army, large 


enough for adequate defense, when it has a constant 
death-rate of ten per cent per annum, and an ever re- 
current one of twenty to thirty per cent, by the sweep 
of some pestilence ? The bubonic plague alone is esti- 
mated to have slain thirty millions of people within two 
centuries in Mediaeval Europe, and to have turned 
whole provinces into little better than deserts. 

In malaria, however, we have a disease enemy of 
somewhat different class and habits. While other great 
infections attack man usually where he is strongest and 
most numerous, malaria, on the contrary, lies in wait 
for him where he is weakest and most scattered, upon 
the frontiers of civilization and the borders of the wil- 
derness. It is only of late years that we have begun to 
realize what a deadly and persistent enemy of the 
frontiersman and pioneer it is. We used to hear much 
of climate as an obstacle to civilization and barrier to 
settlement. Now, for climate we read "malaria." 
Whether on the prairies or even the tundras of the 
North, or by the jungles and swamps of the Equator, 
the thing that killed was eight times out of ten the 
winged messenger of death with his burden of malaria- 
infection. The "chills and fever," " fevernager," 
"mylary," that chattered the teeth and racked the 
joints of the pioneer, from Michigan to Mississippi, 
was one and the same plague with the deadly " jungle 
fever," "African fever," "black fever" of the tropics, 
from Panama to Singapore. Hardly a generation ago, 
along the advancing front of civilization in the Middle 
West, the whole life of the community was colored 
with a malarial tinge and the taste of quinine was 


as familiar as that of sugar. To this day, over some- 
thing like three-quarters of the area of these United 
States, the South, Middle West, and Far West, if you 
feel headachy and bilious and "run down," you sum 
it all up by saying that you are feeling "malarious." 
Dwellers upon the rich bottom-lands expected to shake 
every spring and fall with almost the same regularity 
as they put on and shed their winter clothing. Readers 
of Frank Stockton will remember the gales of merri- 
ment excited by his quaint touch of the incongruous 
in making the prospective bridegroom of the immortal 
Pomona change the,* date of their wedding day from 
Tuesday to Monday, because, on figuring the matter 
out, he had discovered that Tuesday was his "chill- 

Though the sufferer from ague seldom received very 
much sympathy at the time, but was considered a 
fair butt for genial ridicule and chaff, yet even there 
the trouble had its serious side. Through all those 
communities there stalked a well-known and dreaded 
spectre, the so-called "congestive chill," what is now 
known in technical language as the pernicious malarial 
paroxysm. These were like the three warnings of 
death in the old parable. You would probably survive 
the first and might never have another ; but if you had 
your second, it was considered equivalent to a notice 
to quit the country promptly and without counting the 
cost. In my boyhood days in the Middle West, I can 
recall hearing old pioneers tell of little groups of one 
or more families moving out on to some particularly 
rich and virgin bottom-land and losing two or three 


or more members out of each family by congestive 
chills within the first year, and in some cases being 
driven in from the outpost and back to civilization by 
the fearful death-loss. 

A pall of dread hangs over the whole west coast of 
Africa. The factories and trading-posts are haunted 
by the ghosts of former agents and explorers who have 
died there. Some years ago one German company 
had the sinister record that of its hundreds of agents 
sent out to the Gold Coast under a three years' con- 
tract, not one had fulfilled the term! All had either 
died, or been invalided and returned home. It was 
malaria more than any other five influences combined 
that thwarted the French in their attempt to dig the 
Panama Canal and that made the Panama Railroad 
bear the ghastly stigma of having built its forty miles 
of track with a human body for every tie. 

Malaria ever has been, and is yet, the great barrier 
against the invasion of the tropics by the white races ; 
nor has its injurious influence been confined to the 
deaths that it causes, for these gaps in the fighting 
line might be filled by fresh levies drawn from the 
wholesome North. Its fearfully depressing and degen- 
erating effects upon even those who recover from its 
attacks have been still more injurious. It has been 
held by careful students of tropical disease and con- 
ditions that no small part of that singular apathy and 
indifference which steal over the mind and body of 
the white colonist in the tropics, numbing even his 
moral sense, and alternating with furious outbursts 
of what the French have termed "tropical wrath," 


characterized by unnatural cruelty and abnormal dis- 
regard for the rights of others, is the deadly work of 
malaria. It is the most powerful cause, not merely of 
the extinction of the white colonist in the tropics, but 
of the peculiar degeneracy physical, mental, and 
moral which is apt to steal over even the survivors 
who succeed in retaining a foothold. Two particu- 
larly ingenious investigators have even advanced the 
theory that the importation of malaria into the islands 
of Greece and the Italian peninsula by soldiers return- 
ing from African and Southern Asiatic conquests 
had much to do with accelerating, if not actually pro- 
moting, the classic decay of both of these superb civili- 

To come nearer home, there can be little question 
that the baneful, persistent influence of malaria, 
together with the hookworm disease, has had much to 
do both with the degeneracy of the Southern " cracker," 
or "mean white," and with those wild oubursts of 
primitive ferocity in all classes which take the form 
of White Cap raids and lynching mobs. 

However this may be, the disease and the coloniza- 
tion habit brought in a crude way their own remedy. 
The Spanish conquerors of Peru were told by the na- 
tives that a certain bark which grew upon the slopes 
of the Andes was a sovereign remedy for those terrible 
ague seizures. Indian remedies did not stand as high 
in popular esteem as they do now; but they were in 
desperate straits and jumped at the chance. To their 
delight, it proved a positive specific, and a Spanish 
lady of rank, the Countess Chincona, was so delighted 


with her own recovery that she carried back a package 
of the precious Peruvian bark on her return to Europe, 
and endeavored to introduce it. So furious was the 
opposition of the Church, however, to this "pagan" 
remedy that she was completely defeated in her praise- 
worthy attempt and was obliged to confine her minis- 
trations to those who belonged to her, the peasantry 
on her own estate. About half a century later, the new 
remedy excited so much discussion by the numerous 
cures that it effected, that it was considered worthy 
of a special council of the Jesuits, who formally pro- 
nounced it suitable for the use of the faithful, thereby 
attaching to it for many years the name of " Jesuit's 
bark." Virtue, however, is sometimes rewarded in this 
world, and the devoted and enlightened countess has, 
all unknown to herself, attained immortality by attach- 
ing her name, Chincona, softened into cinchona,, 
and hardened into quinine, to the greatest therapeutic 
gift of the gods to mankind. It is not too much to say 
that the modern colonization of the tropics and sub- 
tropics by Northern races, which is one of the greatest 
and most significant triumphs of our civilization, 
would have been almost impossible without it. Its 
advance depended upon two powders, one white and 
the other black, quinine and gunpowder. 

For nearly three centuries we rested content with the 
knowledge that in quinine we had a remedy for malaria, 
which, if administered at the proper time and in ade- 
quate doses, would break up and cure ninety per cent 
of all cases. Just how it did it we were utterly in the 
dark, and many were the speculations that were in- 


dulged in. It was not until 1880, that Laveran, a French 
army surgeon stationed in Algeria, announced the 
discovery in the blood of malarial patients of an organ- 
ism which at first bore his name, the Hematozoon- 
Laveran, now known as the Plasmodium malaria. 
This organism, of all curious places, burrowed into 
and found a home in the little red corpuscles of the 
blood. At periods of forty-eight hours it ripened a 
crop of spores, and would burst out of the corpuscles, 
scattering throughout the blood and the tissues of the 
body, and producing the famous paroxysm. This 

accounted for the most curious and well-marked fea- 

ture of the disease, namely, its intermittent character, 
chill and fever one day, and then a day of comparative 
health, followed by another chill day and so on, as 
long as the infection continued. One problem, how- 
ever, was left open, and that was why certain forms 
of the disease had their chills every fourth day and so 
were called quartan ague. This was quickly solved 
by the discovery of another form of the organism, 
which ripened its spores in three days instead of two. 
So the whole curious rhythm of the disease was estab- 
lished by the rate of breeding or ripening of the spores 
of the organism. Later still another form was discov- 
ered, which had no such regular period of incubation 
and gave rise to the so-called irregular, or autumnal, 
malarial fevers. That form of the fever which had a 
paroxysm every day, the classic quotidian ague, re- 
mained a puzzle for a little longer, but was finally 
discovered to be due chiefly to the presence of two 
broods, or infections, of the organism, which ripened on 


alternate days and hence kept the entire time of the 
unfortunate patient occupied. 

The mystery of the remedial effect of quinine was 
also solved, as it was found that, if administered at 
the time which centuries of experience has shown us 
to be the most effective, between or shortly before the 
paroxysms, it either prevented sporulation or killed 
the spores. So that at one triumphant stroke the mys- 
tery of centuries was cleared up. 

But here will challenge some twentieth-century 
Gradgrind: "This is all very pretty from the point of 
view of abstract science, but what is the practical 
value of it ? The discovery of the plasmodium and its 
peculiarities has merely shown us the how and the why 
of a fact that we had known well and utilized for cen- 
turies, namely, that quinine will cure malaria." Just 
listen to what follows. The story of the plasmodium 
is one of the most beautiful illustrations of the fact that 
there is no such thing as useless or unpractical know- 
ledge. The only thing that makes any knowledge un- 
practical is our more or less temporary ignorance 
of how to apply it. The first question which instantly 
raised itself was, "How did the plasmodium get into 
human blood?" The very sickle-shape of the plas- 
modium turned itself into an interrogation mark. 
The first clew that was given was the new and interest- 
ing one that this organism was a new departure in 
the germ line in that it was an animal, instead of a 
plant, like all the other hitherto known bacilli, bac- 
teria, and other disease-germs. 

It may be remarked in passing that its discovery 


had another incidental practical lesson of enormous 
value, and that was that it paved the way for the iden- 
tification of a whole class of animal parasites causing 
infectious diseases, which already includes the organ- 
isms of Texas fever in cattle, dourine in horses, the 
tsetse fly disease, the dreaded sleeping sickness, and 
finally such world-renowned plagues as syphilis and 
perhaps smallpox. 

Being an animal, the plasmodium naturally would 
not grow upon culture-media like the vegetable bacilli 
and bacteria, and this very fact had delayed its recog- 
nition, but raised at once the probability that it must 
be conveyed into tKe human body by some other 
animal. Obviously, the only animals that bite our 
human species with sufficient frequency and regularity 
to act as transmitters of such a common disease are 
those Ishmaelites of the animal world, the insects. 
As all the evidence pointed toward malaria being 
contracted in the open air, attested by its popular 
though unscientific name mal-aria, " bad air," and as 
of all forms of "bad air" the night air was incom- 
parably the worst, it must be some insect which flew 
and bit by night; which by Sherlock Holmes's pro- 
cess promptly led the mosquito into the dock as the 
suspected criminal. It was n't long before he was, 
in the immortal language of Mr. Devery, "caught 
with the goods on"; and in 1895 Dr. Ronald Ross, 
of the Indian Medical Service, discovered and posi- 
tively identified the plasmodium undergoing a cycle 
of its development in the body of the mosquito. He 
attempted to communicate the disease to birds and 


animals by allowing infected mosquitoes to bite them, 
but was unsuccessful. Two Italian investigators, 
Bignami and Grassi, saw that the problem was one 
for human experiment and that nothing less would 
solve it. Volunteers were called for and promptly 
offered themselves. Their blood was carefully exam- 
ined to make sure that they were not suffering from 
any latent form of malaria. They then allowed them- 
selves to be bitten by infected mosquitoes, and within 
periods varying from six to ten days, eight-tenths 
of them developed the disease. It may be some con- 
solation to our national pride to know that although 
the organism was first identified in the mosquito by an 
Englishman and its transmission to human beings in 
its bite by Italians, the first definite and carefully 
worked-out statement of the relation of the mosquito 
to malaria was made by an American, King of Wash- 
ington, in 1882 ; though it is only fair to say that sug- 
gestions of the possible connection between mosquitoes 
and malaria had, so to speak, been in the air and been 
made from scores of different sources, from the age 
of Augustus onward. 

Another mystery was solved and what a flood 
of light it did pour upon our speculations as to the how 
and wherefore of the catching of malaria! In some 
respects it curiously corroborated and increased our 
respect for popular beliefs and impressions. While 
"bad air" had nothing to do with causing the disease, 
except in so far as it was inhabited by songsters of the 
Anopheles genus, yet it was precisely the air of marshy 
places which was most likely to be " bad " in this sense. 


So that, while in one sense those local wiseacres, who 
would point out to you the pearly mists of evening 
as they rose over low-lying meadows and bottom-lands, 
and inform you that there before your very eyes was 
the "mylary just a-risin' out of the ground," were 
ludicrously mistaken, in another their practical con- 
clusion was absolutely sound ; for it is in just such air, 
at such levels above the surface of the water, that the 
Anopheles most delights to disport himself. Further- 
more, while all raw or misty air is " bad," the night air 
is infinitely more so than that of the day, because this 
is the time at which mosquitoes are chiefly abroad. In 
fact, there can be little doubt that this is part of the 
foundation for that rabid and unreasonable dread of the 
night air which we fresh-air crusaders find the bitterest 
and most tenacious foe we have to fight. We have liter- 
ally discovered the Powers of Darkness in both visible 
and audible form, and they have wings and bite, just 
like the vampire. 

It was also a widespread belief in malarial regions 
that the hours when you are most likely to " git mylary 
inter yer system" were those just before and just after 
sundown ; and now entomologists inform us that these 
are precisely the hours at which the Anopheles mos- 
quito, the only genus that carries malaria, flies abroad. 

Of course, a number of popular causes, such as bad 
drainage, the drinking of water from shallow surface 
wells, damp subsoils under the houses, and especially 
that peculiarly widespread and firmly held article 
of belief that new settlements, where large areas of 
prairie sod were being freshly upturned by the plough, 


were peculiarly liable to the attack and spread of ma- 
laria, had to go by the board, with this important 
reservation, however, that almost every one of these 
alleged causes either implied or was pretty safe to be 
associated with pools or swamps of stagnant water 
in the neighborhood, which would furnish breeding- 
spots for the mosquitoes. 

The discovery explains at once a score of hitherto 
puzzling facts as to the distribution of malaria. Why, 
for instance, in all tropical or other malarious countries, 
those who slept in second and third story bedrooms 
were less likely to contract the disease, supposedly 
because " bad air did n't rise to that height," is 
clearly seen to be due to the fact that the mosquito 
seldom flies more than ten or twelve feet above the 
level of the ground or marsh in which he breeds, ex- 
cept when swept by prevailing winds. It also explained 
why in our Western and Southwestern states the in- 
habitants of the houses situated on the south bank 
of a river, though but a short distance back from the 
stream, would suffer very slightly from malaria, while 
those living upon the north bank, half a mile back, or 
even upon bluffs fifteen or twenty feet above the water 
level, were simply plagued with it. The prevailing 
winds during the summer are from the south and mos- 
quitoes cannot fly a foot against the wind, but will fly 
hundreds of yards, and even the best part of a mile, 
with it. The well-known seasonal preference of the 
disease for warm spring and summer months, and its 
prompt subsidence after a killing frost, were seen 
simply to be due to the influence of the weather upon 


the flight of mosquitoes. Shakespeare's favorite refer- 
ence to "the sun of March that breedeth agues" has 
been placed upon a solid entomological basis by the 
discovery that, like his pious little brother insect, the 
bee, the one converted and church-going member of 
a large criminal family, the mosquito hies himself 
abroad on his affairs at the very first gleam of spring 
sunshine, and will even reappear upon a warm, 
sunny day in November or December. Perhaps 
even some of the popular prejudice against "un- 
seasonable weather" in winter may be traceable to 
this fact. ^ 

Granted that mosquitoes do cause and are the only 
cause of malaria, what are you going to do about it ? 
At first sight any campaign against malaria which in- 
volves the extermination of the mosquito would appear 
about as hopeless as Mrs. Partington's attempt to sweep 
back the rising Atlantic tide with her broom. But a 
little further investigation showed that it is not only 
within the limits of possibility, but perfectly feasible, 
to exterminate malaria absolutely from the mosquito 
end. In the first place, it was quickly found that by 
a most merciful squeamishness on the part of the 
plasmodium, it could live only in the juices of one 
particular genus of mosquito, the Anopheles; and as 
nowhere, not even in the most benighted regions of 
Jersey, has this genus been found to form more than 
about four or five per cent of the total mosquito popu- 
lation, this cuts down our problem to one-twentieth of 
its apparent original dimensions at once. The ordi- 
nary mosquito of commerce (known as Culex) is any 


number of different kinds of a nuisance, but she does 
not carry malaria. 

Here the trails of the extermination party fork, one 
of them taking the perfectly obvious but rather trouble- 
some direction of protecting houses and particularly 
bedrooms with suitable screens and keeping the inhab- 
itants safely behind them from about an hour before 
sundown on. By this simple method alone, parties 
of explorers, of campers, of railroad-builders going 
through swamps, of the laborers on our Panama Canal, 
have been enabled to live for weeks and months in 
the most malarious regions with perfect impunity, so 
long as these precautions were strictly observed. The 
first experiment of this sort was carried out by Bignami 
upon a group of laborers in the famous, or rather in- 
famous, Roman Campagna, whose deadly malarial 
fevers have a classic reputation, and has achieved 
its latest triumphs in the superb success of Colonel 
Gorgas at Panama. While this procedure should never 
be neglected, it is obvious that it involves a good deal 
of irksome confinement and interferes with freedom 
of movement, and it will probably be carried out com- 
pletely only under military or official discipline, or in 
tropical regions where the risks are so great that its 
observance is literally a matter of life or death. 

The other division of malaria-hunters pursued the 
trail of the Anopheles to her lair. There they discovered 
facts which give us practically the whip-hand over 
malarial and other tropical fevers whenever we choose 
to exercise it. It had long been known that the breeding- 
place of mosquitoes was in water ; that their eggs when 


deposited in water floated upon the surface like tiny 
boats, usually glued together into a raft ; that they then 
turned into larvae, of which the well-known " wigglers" 
in the water-butt or the rain-barrel are familiar ex- 
amples ; and that they finally hatched into the complete 
insect and rose into the air. 

Obviously, there were two points at which the de- 
stroyers might strike, the egg and the larvae. It was 
first found that, while the eggs required no air for their 
development, the larvae wiggled up to the surface and 
inhaled it through curious little tubes developed for 
this purpose, oddly enough from their tail-ends. If 
some kind of film could be spread over the surface of 
the water, through which the larvae could not obtain 
air, they would suffocate. The well-known property of 
oil in " scumming over" water was recalled, two or 
three stagnant pools were treated with it, and to the de- 
light of the experimenters, not a single larva was able to 
develop under the circumstances. Here was insecticide 
number one. The cheapest of oils, crude petroleum, if 
applied to the pool or marsh in which mosquitoes breed, 
will almost completely exterminate them. Scores of 
regions and areas to-day, which were once almost un- 
inhabitable on account of the plague of mosquitoes, 
are now nearly completely free from these pests by 
this simple means. An ounce to each fifteen square 
feet of water-surface is all that is required, though 
the oiling needs to be repeated carefully several times 
during the season. 

But what of the eggs ? They require no air, and it 
was found impossible to poison them without simply 


saturating the water with powerful poisons; but an 
unexpected ally was at our hand. It was early noted 
that mosquitoes would not breed freely in open rivers 
or in large ponds or lakes, but why this should be 
the case was a puzzle. One day an enthusiastic mos- 
quito-student brought home a number of eggs of 
different species, which he had collected from the neigh- 
boring marshes, and put them into his laboratory 
aquarium for the sake of watching them develop and 
identifying their species. The next morning, when he 
went to look at them, they had totally disappeared. 
Thinking that perhaps the laboratory cat had taken 
them, and overlooking a most contented twinkle in 
the corner of the eyes of the minnows that inhabited 
the aquarium, he went out and collected another 
series. This time the minnows were ready for him, 
and before his astonished eyes promptly pounced on 
the raft of eggs and swallowed them whole. Here was 
the answer at once : mosquitoes would not develop 
freely where fish had free access; and this fact is our 
second most important weapon in the crusade for their 
extermination. If the pond be large enough, all that 
is necessary is simply to stock it with any of the local 
fish, minnows, killies, perch, dace, bass, and presto ! 
the mosquitoes practically disappear. If it be near 
some larger lake or river containing fish, then a chan- 
nel connecting the two, to allow of its stocking, is all 
that is required. 

On the Hackensack marshes to-day trenches are 
cut to let the water out of the tidal pools ; while in 
low-lying areas, which cannot be thus drained, the 


central lowest spot is selected, a barrel is sunk at 
this spot, and four or five "killie" fish are placed in 
it. Trenches are cut converging into this barrel from 
the whole of the area to be drained, and behold, no 
more mosquitoes can breed in that area, and, in the 
language of the day, "get away with it." 

Finally, most consoling of all, it was discovered 
that, while the ordinary Culex mosquito can breed, 
going through all the stages from the egg to the com- 
plete insect, in about fourteen days, so that any 
puddle which will remain wet for that length of time, 
or even such exceedingly temporary collections of 
water as the rain caught in a tomato-can, in an old 
rubber boot, in broken crockery, etc., will serve her 
for a breeding-place, the Anopheles on the other hand 
takes nearly three months for the completion of her 
development. So that, while a region might be simply 
swarming with ordinary mosquitoes, it would fre- 
quently be found that the only places which fulfilled 
all the requirements for breeding-homes for the Ano- 
pheles, that is, isolation from running water or larger 
streams, absence of fish, and persistence for at least 
three months continuously, would not exceed five or 
six to the square mile. Drain, fill up, or kerosene these 
puddles, for they are often little more than that, 
and you put a stop to the malarial infection of that par- 
ticular region. Incredible as it may seem, places in 
such a hotbed of fevers as the west coast of Africa, 
which have been thoroughly investigated, drained, and 
cleaned up by mosquito-brigades, have actually been 
freed from further attacks of fever by draining and 


filling not to exceed twenty or thirty of these breeding- 

In short, science is prepared to say to the community : 
" I have done my part in the problem of malaria. It is 
for you to do the rest." There is literally no neighbor- 
hood in the temperate zone, and exceedingly few in 
the tropics, which cannot, by intelligent cooperation 
and a moderate expense, be absolutely rid first of 
malaria, and second of all mosquito-pests. It is only 
a question of intelligence, cooperation, and money 
The range of flight of the ordinary mosquito is seldom 
over two or three hundred yards, save when blown 
by the wind, and more commonly not more than as 
many feet, and thorough investigation of the ground 
within the radius of a quarter of a mile of your house 
will practically disclose all the danger you have to 
apprehend from mosquitoes. It is a good thing to be- 
gin with your own back yard, including the water- 
butt, any puddles or open cesspools or cisterns, and 
any ornamental water gardens or lily-ponds. These 
latter should be stocked with fish or slightly oiled 
occasionally. If there be any accumulations of water, 
like rain-barrels or cisterns, which cannot be abol- 
ished, they should either be kept closely covered or 
well screened with mosquito netting. 

It might be remarked incidentally in passing, that 
the only really dangerous sex in mosquitodom, as 
elsewhere, is the female. The male mosquito, if he 
were taxed with transmitting malaria, would have a 
chance to reecho Adam's cowardly evasion in the 
Garden of Eden, " It was the woman that thou gavest 


me." Both sexes of mosquitoes under ordinary condi- 
tions are vegetable feeders, living upon the juices of 
plants. But when the female has thrown upon her the 
tremendous task of ripening and preparing her eggs 
for deposition, she requires a meal of blood which 
may be a comfort to our vegetarian friends, or it may 
not. Either she requires a meal of blood to nerve her up 
to her criminal deed, or, when she has some real work 
to do, she has to have some real food. 

The mosquito-brigade have still another method of 
checking the spread of malaria, at first sight almost 
a whimsical one, no less than screening the patient. 
The mosquito, of course, criminal as she is, does not 
hatch the parasites de novo in her own body, but simply 
sucks them up in a meal of blood from some previous 
victim. Hence by careful screening of every known 
case of malaria, mosquitoes are prevented from be- 
coming infected and transmitting the disease. In- 
stead of the screens protecting the victims from the 
mosquitoes, they protect the mosquitoes against the 

This explains why hunters, trappers, and Indians 
may range a region for years, without once suffering 
from malaria, while as soon as settlers begin to come in 
in considerable numbers, it becomes highly malarious. 
It had to be infected by the coming of a case of the 

The notorious prevalence of malaria on the frontier 
is due to the introduction of the plasmodium into a 
region swarming with mosquitoes, where there are few 
window-screens or two-story houses. 


No known race has any real immunity against ma- 
laria. The negro and other colored races, it is true, are 
far less susceptible ; but this we now know applies only 
to adults, as the studies of Koch in Africa showed that 
a large percentage of negro children had the plasmo- 
dium in their blood. No small percentage of them die 
of malaria, but those who recover acquire a certain 
degree of immunity. Possibly they may be able to 
acquire this immunity more easily and with less fatality 
than the white race, but this is the extent of their superi- 
ority in this regard. The negro races probably represent 
the survivors of primitive men, who were too unenter- 
prising to get away from the tropics, and have had to 
adjust themselves as best they might. 

The serious injury wrought in the body by malaria 
is a household word, and a matter of painfully familiar 
experience. Scarcely an organ in the body escapes 
damage, though this may not be discovered till long 
after the " fever-and-ague " has been recovered from. 

As the parasite breeds in the red cells of the blood, 
naturally its first effect is to destroy huge numbers of 
these, producing the typical malarial anosmia, or blood- 
lessness. Instead of 5,000,000 to the cubic centimetre 
of blood the red cells may be reduced to 2,000,000 
or even 1,500,000. The breaking down of these red 
cells throws their pigment or coloring-matter afloat 
in the blood ; and soaking through all the tissues of the 
body, this turns a greenish-yellow and gives the well- 
known sallow skin and yellowish whites of the eyes of 
swamp-dwellers and "river-rats." 

The broken-down scraps of the red blood-cells, 



together with the toxins of the parasite, are carried 
to the liver and spleen to be burned up or purified 
in such quantities that both become congested and 
diseased, causing the familiar "biliousness," so char- 
acteristic of malaria. 

The spleen often becomes so enormously enlarged 
that it can be readily felt with the hand in the left side 
below the ribs, so that it is not only relied upon as a 
sign of malaria in doubtful cases, but has even received 
the popular name of the "ague-cake'* in malarious 

So full is the blood of the parasites, that they may 
actually choke up the tiny blood-vessels and capillaries 
in various organs, so as to block the circulation and 
cause serious and even fatal congestions. Obstruc- 
tions of this sort may occur in the brain, the liver, the 
coats of the stomach, or intestines, and the kidneys; 
and they are the chief cause of the deadly "conges- 
tive chills," or pernicious malarial paroxysms, which 
we have alluded to. 

The kidneys are particularly liable to be attacked 
in this way; indeed, one of their involvements is so 
serious and fatal in the tropics as to have been given 
a separate name, " Blackwater fever," from the quan- 
tities of broken-down blood which appear in and 
blacken the urine. 

The vast majority of attacks of malaria are com- 
pletely recovered from, like any other infection, but it 
can easily be seen what an injurious effect upon the 
system may be produced by successive attacks, 
keeping the entire body saturated with the poison; 


while there is serious risk of the parasite sooner or 
later finding some weak spot in the body, kidney, 
liver, nervous system, where its incessant battering 
works permanent damage. 

How long the infection may lurk in the body is 
uncertain ; certainly for months, and possibly for years. 
Many cases are on record which had typical chills 
and fever, with abundance of plasmodia in the blood, 
years after leaving the tropics or other malarious dis- 
tricts ; but there is often the possibility of a recent re- 

Altogether, malaria is a remarkably bad citizen in 
any community, and its stamping-out is well worth all 
it costs. 


IT is N'T 

"TITTHAT 'S in a name ? All the aches and pains 
T V that came out of Pandora's box, if the name 
happens to be rheumatism. It is a term of wondrous 
elasticity. It will cover every imaginable twinge in any 
and every region of ^the body and explain^ none of 
them. It is a name that means just nothing, and yet 
it is in every man's vocabulary, from proudest prince 
to dullest peasant. Its derivative meaning is little short 
of an absurdity in its inappropriateness, from the Greek 
reuma (a flowing), hence, a cold or catarrh. It is still 
preserved for us in the familiar " salt rheum " (eczema) 
and "rheum of the eyes" of our rural districts. But 
this very indefiniteness, absurdity if you will, is a 
comfort both to the sufferer and to the physician. 
Moreover, incidentally, to paraphrase Portia's famous 

It blesseth him that has and him that treats ; 

'T is mightier than the mightiest. 

It doth fit the throned monarch closer than his crown. 

To the patient it is a satisfying diagnosis and satis- 
factory explanation in one ; to the doctor, a great saving 
of brain-fag. When we call a disease rheumatism, we 
know what to give for it even if we don't know what 
it is. As the old German distich runs, 


Was man kann nicht erkennen, 
Muss er Rheumatismus nennen. 1 

However, in spite of the confusion produced by 
this wholesale and indiscriminate application of the 
term to a host of widely different, painful conditions, 
many of which have little else in common save that they 
hurt and can be covered by this charitable name-blanket, 
a few definite facts are crystallizing here and there out 
of the chaos. The first is, that out of this swarm of 
different conditions there can be isolated one large 
and important central group which has the characters 
of a well-defined and constant disease-entity. This is 
the disease known popularly as rheumatic fever, and 
technically as acute rheumatism or acute articular 
rheumatism. In fact, the commonest division is to 
separate the "rheumatisms" into two great groups: 
acute, covering the "fever" form, and chronic, con- 
taining all the others. From a purely scientific point 
of view, this classification has rather an undesirable 
degree of resemblance to General Grant's famous 
division of all music into two tunes : one of which was 
Old Hundred, and the other was n't. But for practical 
purposes it has certain merits and may pass. 

Every one has seen, or known, or had, the acute 
articular form of rheumatism, and when once seen there 
is no difficulty in recognizing it again. It is one of the 
most striking and most abominable of disease-pictures, 
beginning with high fever and headache, then tender- 
ness, quickly increasing to extreme sensitiveness in 
one or more of the larger joints, followed by drenching 
1 What one cannot recognize he must call rheumatism. 


sweats of penetrating acid odor. The joint attacked 
becomes red, swollen, and glossy, so tender that merely 
pointing a finger at it will send a twinge of agony 
through the entire body, and the patient lies rigid and 
cramped for fear of the agony caused by the slightest 
movement. The tongue becomes coated and foul, the 
blood-cells are rapidly broken down, and the victim 
becomes ashy pale. He is worn out with pain and fever, 
yet afraid to fall asleep for fear of unconsciously moving 
the inflamed joint and waking in tortures; and alto- 
gether is about as acutely uncomfortable and com- 
pletely miserable as any human being can well be made 
in so short a time. 

Fortunately, as with its twin brother, the grip, the 
bark of rheumatism is far worse than its bite ; and a 
striking feature of the disease is its low fatality, es- 
pecially when contrasted with the fury of its onslaught 
and the profoundness of the prostration which it pro- 
duces. Though it will torture its victim almost to 
the limits of his endurance for days and even weeks at 
a stretch, it seldom kills directly. Its chief danger 
lies in the legacies which it bequeaths. Though, like 
nearly all fevers, it is self-limited, tends to run its 
course and subside when the body has manufactured 
an antitoxin in sufficient amounts, it is unique in an- 
other respect, and that is in the extraordinary variabil- 
ity of the length of its "course." This may range any- 
where from ten days to as many weeks, the " average 
expectation of life" being about six weeks. The ago- 
nizing intensity of the pain and acute edge of the dis- 
comfort usually subside in from five to fifteen days, 


especially under competent care. When the tempera- 
ture falls, the drenching sweats cease, the joints be- 
come less exquisitely painful, and the patient gradu- 
ally begins to pull himself together and to feel as if life 
were once more worth living. He is not yet out of the 
woods, however, for while the pain is subsiding in the 
joints which have been first attacked, another joint 
may suddenly flare up within ten or twelve hours, and 
the whole distressing process be repeated, though 
usually on a somewhat milder and shorter scale. This 
uncertainty as to how many joints in the body may be 
attacked, is, in fact, one of the chief elements in making 
the duration of the disease so irregular and incalcu- 

Even when the frank and open progress of the dis- 
ease through the joints of the body has come to an end, 
the enemy is still lying in wait and reserving his most 
deadly assault. Distressing and crippling as are the 
effects of rheumatism upon the joints and tendons, 
its most deadly and permanent damage is wrought 
upon the heart. Fortunately, this vital organ is not 
attacked in more than about half the cases of acute 
rheumatism, and in probably not more than one-third 
of these are the changes produced either serious or 
permanent, especially if the case be carefully watched 
and managed. But it is not too much to say that, of 
all cases of serious or "organic" heart disease, rheu- 
matism is probably responsible for from fifty to seventy 
per cent. The same germ or toxin which produces the 
striking inflammatory changes in the joints may be 
carried in the blood to the heart, and there attack either 


the lining and valves of the heart (endocardium), 
which is commonest, or the covering of the heart (peri- 
cardium), or the heart-muscle. So intense is the in- 
flammation, that parts of the valves may be literally 
eaten away by ulceration, and when these ulcers heal 
with formation of scar-tissue as everywhere else in the 
body, the flaps of the valves may be either tied together 
or pulled out of shape, so that they can no longer pro- 
perly close the openings of the heart-pump. This con- 
dition, or some modification of it, is what we usually 
mean when we speak of "heart disease," or "organic 
heart disease." The, effect upon the heart-pump is 
similar to that which would be produced by cutting 
or twisting the valve in the "bucket" of a pump or 
in a bulb syringe. 

In severe cases of rheumatism the heart may be 
attacked within the first few days of the disease, but 
usually it is not involved until after the trouble in the 
joints has begun to subside ; and no patient should be 
considered safe from this danger until at least six 
weeks have elapsed from the beginning of the fever. 
The few cases (not to exceed one or two per cent) of 
rheumatic fever which go rapidly on to a fatal termi- 
nation, usually die from this inflammation of the heart, 
technically known as endocarditis. The best way of 
preventing this serious complication and of keeping 
it within moderate limits, if it occurs, is absolute rest 
in bed, until the danger period is completely passed. 

Now comes another redeeming feature of this trouble- 
some disease, and that is the comparatively small per- 
manent effects which it produces upon the joints in the 


way of crippling, or even stiffening. To gaze upon a 
rheumatic knee-joint, for instance, in the height of 
the attack, swollen to the size of a hornet's nest, 
hot, red, throbbing with agony, and looking as if it 
were on the point of bursting, one would almost 
despair of saving the joint, and the best one would feel 
entitled to expect would be a roughening of its sur- 
faces and a permanent stiffening of its movements. 

On the contrary, when once the fury of the attack 
has passed its climax, especially if another joint should 
become involved, the whole picture changes as if by 
magic. The pain fades away to one-fifth of its former 
intensity within twenty-four, or even within twelve 
hours ; three-fourths of the swelling follows suit in forty- 
eight hours; and within three or four days' time the 
patient is moving the joint with comparative ease and 
comfort. After he gets up at the end of his six weeks, 
the knee, though still weak and stiff and sore, within a 
few weeks' time "limbers up" completely, and usu- 
ally becomes practically as good as ever. In short, the 
violence and swiftness of the onset are only matched 
by the rapidity and completeness of the retreat. It 
would probably be safe to say that not more than one 
joint in fifty, attacked by rheumatism, is left in any way 
permanently the worse. 

But, alas ! to counterbalance this mercifulness in the 
matter of permanent damage, unlike most other infec- 
tions, one attack of rheumatic fever, so far from pro- 
tecting against another, renders both the individual and 
the joint more liable to other attacks. The historic 
motto of the British in the War of 1812 might be para- 


phrased into, " Once rheumatic, always rheumatic." 
The disease appears to be lost to all sense of decency 
and reason ; and to such unprincipled lengths may it go, 
that I have actually known one luckless individual who 
had the unenviable record of seventeen separate and 
successive attacks of rheumatic fever. As he expressed 
it, he had "had rheumatism every spring but two for 
nineteen years past." Yet only one ankle-joint was 
appreciably the worse for this terrific experience. 

Obviously, the picture of acute rheumatism carries 
upon its face a strong suggestion of its real nature and 
causation. The high y temperature, the headache, the 
sweats, the fierce attack and rapid decline, the self- 
limited course, the tendency to spread from one joint 
to another, from the joints to the heart, from the heart 
to the lungs and the kidneys, all stamp it unmistakably 
as an infection, a fever. On the other hand, there are 
two rather important elements lacking in the infection- 
picture: one, that, although it does at times occur in 
epidemics, it is very seldom transmitted to others ; the 
other, that one attack does not produce immunity or 
protect against another. The majority of experts are 
now practically agreed that acute rheumatism, or rheu- 
matic fever, is probably due to the invasion of the sys- 
tem by some microorganism or germ. When, however, 
we come to fixing upon the particular bacillus, or micro- 
coccus, there is a wide divergence of opinion, some six 
or seven different eminent investigators having each his 
favorite candidate for the doubtful honor. In fact, it is 
our inability as yet positively to identify and agree upon 
the causal germ that makes our knowledge of the entire 


subject still so regrettably vague, and renders either a 
definite classification or successful treatment so difficult. 
The attitude of the most careful and experienced 
physicians and broad-minded bacteriologists may be 
roughly summed up in the statement that acute rheuma- 
tism is probably due to some germ or germs, but that the 
question is still open which particular germ is at fault, 
and even whether the group of symptoms which we call 
rheumatism may not possibly be produced by a num- 
ber of different organisms, acting upon a particular 
type of constitution or susceptibility. There is no diffi- 
culty in finding germs of all sorts, principally micro- 
cocci, in the blood, in the tissues about the joints, and 
on the heart-valves of patients with rheumatism, and 
these germs, when injected into animals, will not in- 
frequently produce fever and inflammatory changes 
in the joints, roughly resembling rheumatism. But the 
difficulty so far has been, first, that these organisms are 
of several different kinds and distinct species; and 
second, and even more important, that almost any of 
the organisms of the common infectious diseases are 
capable at times of producing inflammation of the joints 
and tendons. For instance, the third commonest point 
of attack of the tubercle bacillus, after the lungs and the 
glands, is the bones and joints, as illustrated in the 
sadly familiar " white-swelling of the knee " and hip- 
joint disease. All the so-called septic organisms, which 
produce suppuration and blood-poisoning in wounds 
and surgery, may, and very frequently do, attack the 
joints ; while nearly all the common infections, such as 
typhoid, scarlet fever, pneumonia, and even measles, 


influenza, and tonsillitis, may be followed by severe 
joint symptoms. 

In fact, we are coming to recognize that diseases of 
the joints, like diseases of the nervous system, are among 
the frequent results of any and all of the acute infec- 
tious diseases or fevers ; and we now trace from fifty to 
seventy-five per cent of both joint troubles and degener- 
ations of the nervous system to this cause. Two-thirds, 
for instance, of our cases of hip-joint disease and of 
spinal disease (caries) are due to tuberculosis. 

The puzzling problem now before pathologists is the 
sorting out of these innumerable forms of joint in- 
flammations and the^ splitting off of those which are 
clearly due to certain specific diseases, from the great, 
central group of true rheumatism. Most of these joint 
inflammations which are due to recognized germs, such 
as the pus-organisms of surgical fevers, tuberculosis, 
and typhoid, differ from true rheumatism in that they 
go on to suppuration (formation of "matter") and 
permanently cripple the joint to a greater or less degree. 
So that there is probably a germ or group of germs which 
produces the swift attack and rapid subsidence and 
other characteristic features of true rheumatism, even 
though we have not yet succeeded in sorting them out 
of the swarm. So confident do we feel of this, that al- 
though, as will be shown, there are probably other 
factors involved, such as exposure, housing, occupation, 
food, and heredity, yet the best thought of the profes- 
sion is practically agreed that none of these would 
alone produce the disease, but that they are only ac- 
cessory causes plus the micrococcus. In practically 


all our modern textbooks of medicine, rheumatism is 
included under the head of infections. 

This theory of causation, confessedly provisional and 
imperfect as it is, helps us to harmonize the other known 
facts about the disease; it has already greatly improved 
our treatment and given us a foothold for attacking the 
problem of prevention. For instance, it has long been 
known that rheumatism was very apt to follow tonsil- 
litis or other forms of sore throat; indeed, many of the 
earlier authorities put down tonsillitis as one of the 
great group of "rheumatic" disturbances, and per- 
sons of rheumatic family tendency were supposed to 
have tonsillitis in childhood and rheumatism in later 
life. Not more than ten or fifteen per cent of all cases 
gave a history of tonsillitis ; but since we have broadened 
our conception of infection and begun to inquire, not 
merely for symptoms of tonsillitis, but also for those of 
influenza, " common colds," measles, whooping-cough, 
and the like, we reach the most significant result of 
finding that forty to sixty per cent of our cases of rheu- 
matism have been preceded, anywhere from one to 
three weeks before, by an attack of some sort of " cold," 
sore throat, oatarrhal fever, cough, bronchitis, or other 
group of disturbances due to a mild infection. Fur- 
ther, it has long been notorious that when a rheumatic 
individual " catches cold " it is exceedingly apt to " set- 
tle in the joints," and, if these cases happen to come 
under the eye of a physician, they are recognized as 
secondary attacks of true rheumatism. In other words, 
the " cold" may simply be a second dose of the same 
germ which caused the primary attack of rheumatism. 


This brings us to the widespread article of popular 
belief that rheumatism is most commonly due to cold, 
exposure, chill, or damp. Much of this is found on in- 
vestigation to be due to the well-known historic confu- 
sion between " cold," in the sense of exposure to cold 
air, and "cold," in the sense of a catarrh or influenza, 
with running at the nose, coughing, sore throat, and 
fever, a group of symptoms now clearly recognized to 
be due to an infection. In short, the vast majority of 
common colds are unmistakably infections, and spread 
from one victim to another, and this is the type of 
" cold "which causes the majority of rheumatic attacks. 

The chill, which any one who is " coming down " with 
a cold experiences, and usually refers to a draft or a cold 
room, is, in nine cases out of ten, the rigor which pre- 
cedes the fever, and has nothing whatever to do with 
the external temperature. The large majority of our 
cases of rheumatism can give no clear or convincing his- 
tory of exposure to wet, cold, or damp. But popular 
impression is seldom entirely mistaken, and there can 
be no question that, given the presence of the infectious 
germ, a prolonged exposure to cold, and particularly 
to wet, will often prove to be the last straw which will 
break down the patient's power of resistance, and de- 
termine an attack of rheumatism. 

This climatic influence, however, is probably not re- 
sponsible for more than fifteen or twenty per cent of all 
cases, and, popular impression to the contrary notwith- 
standing, the liability of outdoor workers who are sub- 
ject to severe exposure, such as lumbermen, fishermen, 
and sailors, is only slightly greater than that of indoor 


workers. The highest susceptibility, in fact, not merely 
to the disease, but also to the development of serious 
heart involvements, is found among domestic servants, 
particularly servant girls, agricultural laborers and their 
families (in districts where wages are low and cottages 
bad) , and slum-dwellers ; in fact, those classes which are 
underfed, overworked, badly housed, and crowded to- 
gether. Diet has exceeding little to do with the disease, 
and, so far from meat or high living of any sort pre- 
disposing to it, it is most common and most serious in 
precisely those classes which get least meat or luxuries 
of any sort, and are from stern necessity compelled to 
live upon a diet of cereals, potatoes, cheap fats, and 
coarse vegetables. 

Even its relations to the weather and seasons support 
the infection theory. Its seasonal occurrence is very 
similar to that of pneumonia, rarest in summer, com- 
monest in winter, the highest percentage of cases oc- 
curring in the late fall and in the early spring ; in other 
words, just at those times when people are first begin- 
ning to shut themselves up for the winter, light fires, and 
close windows, and at the end of their long period of 
winter imprisonment, when both their resisting power 
has been reduced to the lowest ebb in the year and in- 
fections of all sorts have had their most favorable con- 
ditions of growth for months. 

The epidemics of rheumatism, which occasionally 
occur, probably follow epidemics of influenza, tonsil- 
litis, or other mild infections, and instances of two or 
more cases of rheumatism in one family or household 
are most rationally explained as due to the spread of the 


precedent infection from one member of the family to 
the other. Instances of the direct transmission of the 
disease from one patient to another are exceedingly rare. 

Our view of the infectious causation of rheumatism, 
vague as it is, has given us already our first intelligent 
prospect of prevention. Whatever may be the character 
of a germ or germs, the vast majority of them agree in 
making the nose and throat their first point of attack and 
of entry into the system. Hence, vigorous antiseptic 
and other rational treatment of all acute disturbances 
of the nose and throat, however slight, will prove a valu- 
able preventive and diminisher of the percentage of 
rheumatism. This simply emphasizes again the truth 
and importance of the dictum of modern medicine, 
"Never neglect a cold," since we are already able to 
trace, not merely rheumatism, but from two-thirds to 
three-fourths of our cases of heart disease, of kidney 
trouble, and of inflammations of the nervous system, to 
those mild infections which we term "colds," or to 
other definite infectious diseases. 

Not only is this good a priori reasoning, but it has 
been demonstrated in practice. One of our largest 
United States army posts had acquired an unenviable 
reputation from the amount of rheumatism occurring 
in the troops stationed there. A new surgeon coming 
to take charge of the post set about investigating the 
cause of this state of affairs, and came to the conclusion 
that the disease began as, or closely followed, tonsillitis 
and other forms of sore throat. He accordingly saw to 
it that every case of tonsillitis, of cold in the head, or 
sore throat was vigorously treated with local germicides 


and with intestinal antiseptics and laxatives, until it 
was completely cured ; with the result that in less than 
a year he succeeded in lowering the percentage of cases 
of rheumatism per company nearly sixty per cent. 

At some of our large health-resorts, where great num- 
bers of cases of rheumatism are treated, it has been dis- 
covered that if a case of common cold, or tonsillitis, hap- 
pens to come into the establishment, and runs through 
the inmates, nearly half of the rheumatic patients at- 
tacked will have a relapse or new seizure of their rheu- 
matism. Accordingly, a rigorous and hawk-like watch is 
kept for every possible case of cold, tonsillitis, or sore 
throat entering the house ; the patient is promptly iso- 
lated and treated on rigidly antiseptic principles, with 
the result that epidemics of relapses of rheumatism in 
the inmates have greatly diminished in frequency. 

If every case of cold or sore .throat were promptly and 
thoroughly treated with antiseptic sprays and washes 
such as any competent physician can direct his patients 
to keep in the house, in readiness for such an emer- 
gency, combined with laxatives and intestinal antisep- 
tic treatment, and, above all, with rest in bed as long as 
any rise of temperature is present, there would be a 
marked diminution in both the frequency and the 
severity of rheumatism. If to this were added an 
abundant and nutritious dietary, good ventilation 
and pure air, an avoidance of overwork and over- 
strain, we should soon begin to get the better of this 
distressing disease. In fact, while positive data are 
lacking, on account of the small fatality of rheumatism 
and its consequent infrequent appearance among the 


causes of death in our vital statistics, yet it is the almost 
unanimous opinion of physicians of experience that the 
disease is distinctly diminishing, as a result of the marked 
improvement in food, housing, wages, and living con- 
ditions generally, which modern civilization has already 
brought about. 

So much for acute rheumatism. Vague and un- 
satisfactory as is our knowledge of it, it is, unfor- 
tunately, clearness and precision itself when con- 
trasted with the welter of confusion and fog which 
covers our ideas about the chronic variety. The catho- 
licity of the term is something incredible. Every chronic 
pain and twinge, from corns to locomotor ataxia, and 
from stone-in-the-kidney to tic-douloureux, has been 
put down as " rheumatism." It is little better than a 
diagnostic garbage-dump or dust-heap, where can be 
shot down all kinds of vague and wandering pains in 
joints, bones, muscles, and nerves, which have no 
visible or readily ascertainable cause. Probably at 
least half of all the discomforts which are put down as 
" rheumatism " of the ankle, the elbow, the shoulder, 
are not rheumatism at all, in any true or reasonable 
sense of the term, but merely painful symptoms due to 
other perfectly definite disease conditions of every im- 
aginable sort. The remaining half may be divided into 
two great groups of nearly equal size. One of these, 
like acute rheumatism, is closely related to, and prob- 
ably caused by, the attack of acute infections of milder 
character, falling upon less favorable soil. The other 
is of a vaguer type and is due, probably, to the accumu- 
lation of poisonous waste-products in the tissues, set- 


ting up irritative and even inflammatory changes in 
nerve, muscle, and joint. Either of these may be made 
worse by exposure to cold or changes in the weather. 
In fact, this is the type of rheumatism which has such 
a wide reputation as a barometer and weather prophet, 
second only to that of the United States Signal Service. 
When you " feel it in your bones," you know it is going 
to snow, or to rain, or to clear up, or become cloudy, 
or whatever else may happen to follow the sensation, 
merely because all poisoned and irritated nerves are 
more sensitive to changes in temperature, wind-direc- 
tion, moisture, and electric tension, than sound and 
normal ones. The change in the weather does not 
cause the rheumatism. It is the rheumatism that en- 
ables us to predict the change in the weather, though 
we have no clear idea what that change will be. 

Probably the only statement of wide application that 
can be made in regard to the nature of chronic rheu- 
matism is that a very considerable percentage of it is 
due to the accumulation of poisons (toxins) in the 
nerves supplying joints and muscles, setting up an ir- 
ritation (neurotoxis) , or, in extreme cases, an inflam- 
mation of the nerve (neuritis), which may even go on 
to partial paralysis, with wasting of the muscles sup- 
plied. The same broad principles of causation and pre- 
vention, therefore, apply here as in acute rheumatism. 

The most important single fact for rheumatics of all 
sorts, whether acute or chronic, to remember is that 
they must avoid exposure to colds, in the sense of in- 
fections of all sorts, as they would a pestilence; that 
they must eat plenty of rich, sound, nourishing food ; 


live in well-ventilated rooms ; take plenty of exercise in 
the open air, to burn up any waste poisons that may be 
accumulating in the tissues ; dress lightly but warmly 
(there is no special virtue in flannels), and treat every 
cold or mild infection which they may be unfortunate 
enough to catch, according to the strictest rigor of the 
antiseptic law. 

The influence of diet in chronic rheumatism is almost 
as slight as in the acute form. Persons past middle age 
who can afford to indulge their appetites and are in- 
clined to eat and drink more than is good for tljem, and, 
what is far more important, to exercise much less, may 
so embarrass their liver and kidneys as to create accumu- 
lations of waste products in the blood sufficient to cause 
rheumatic twinges. The vast majority, however, of the 
sufferers from chronic rheumatism, like those from the 
acute form, are underfed rather than overfed, and a 
liberal and abundant dietary, including plenty of red 
meats, eggs, fresh butter, green vegetables, and fresh 
fruits, will improve their nutrition and diminish their 
tendency to the attacks. 

There appears to be absolutely no rational founda- 
tion for the popular belief that red meats cause rheu- 
matism, either from the point of view of practical 
experience, or from that of chemical composition. We 
now know that white meats of all sorts are quite as rich 
in those elements known as the purin bodies, or uric- 
acid group, as red meats, and many of them much 
richer. It may be said in passing, that this last-men- 
tioned bugbear of our diet-reformers is now believed to 
have nothing whatever to do with rheumatism, and 


probably very little with gout, and that the ravings of 
Haig and the Uric-Acid School generally are now thor- 
oughly discredited. Certainly, whenever you see any 
remedy or any method of treatment vaunted as a cure 
for rheumatism, by neutralizing or washing out uric 
acid, you may safely set it down as a fraud. 

One rather curious and unexpected fact should, 
however, be mentioned in regard to the relation of diet 
to rheumatism, and that is that many rheumatic patients 
have a peculiar susceptibility to some one article of food. 
This may be a perfectly harmless and wholesome thing 
for the vast majority of the species, but to this individual 
it acts as a poison and will promptly produce pains in 
the joints, redness, and even swelling, sometimes ac- 
companied by a rash and severe disturbances of the di- 
gestive tract. The commonest offenders form a curious 
group in their apparent harmlessness, headed as they 
are by strawberries, followed by raspberries, cherries, 
bananas, oranges ; then clams, crabs, and oysters ; then 
cheese, especially overripe kinds ; and finally, but very 
rarely, certain meats, like mutton and beef. What is 
the cause of this curious susceptibility we do not know, 
but it not infrequently occurs with this group of foods 
in rheumatics and also in asthmatics. 

Both rheumatics and asthmatics are also subject to 
attacks of urticaria or " hives " (nettle-rash) , from these 
and other special articles of diet. 

As to principles of treatment in a disease of so varied 
and indefinite a character, due to such a multitude of 
causes, obviously nothing can be said except in the 
broadest and sketchiest of outline. The prevailing. 


tendency is, for the acute form, rest in bed, the first 
and most important, also the second, the third, and 
the last element in the treatment. This will do more to 
diminish the severity of the attack and prevent the oc- 
currence of heart and other complications than any 
other single procedure. 

After this has been secured, the usual plan is to as- 
sist nature in the elimination of the toxins by alka- 
lies, alkaline mineral waters, and other laxatives; to 
relieve the pain, promote the comfort, and improve the 
rest of the patient by a variety of harmless nerve- 
deadeners or pain-relievers, chief among which are the 
salicylates, aspirin, and the milder coal-tar products. 
By a judicious use of these in competent hands the pain 
and distress of the disease can be very greatly re- 
lieved, but it has not been found that its duration is 
much shortened thereby, or even that the danger of 
heart and other complication is greatly lessened. The 
agony of the inflamed joints may be much diminished 
by swathing in cotton-wool and flannel bandages, or 
in cloths wrung out of hot alkalies covered with oiled 
silk, or by light bandages kept saturated with some 
evaporating lotion containing alcohol. As soon as the 
fever has subsided, then hot baths and gentle massage 
of the affected joints give great relief and hasten the 
cure. But, when all is said and done, the most import- 
ant curative element, as has already been intimated, is 
six weeks in bed. 

In the chronic form the same remedies to relieve the 
pain are sometimes useful, but very much less effective, 
and often of little or no value. Dry heat, moist heat, 


gentle massage, and prolonged baking in special metal 
ovens, will often give much relief. Liniments of all 
sorts, from spavin cures to skunk oil, are chiefly of 
value in proportion to the amount of friction and mas- 
sage administered when they are rubbed in. 

In short, there is no disease under heaven in which 
so much depends upon a careful study of each individ- 
ual case and adaptation of treatment to it personally, 
according to its cause and the patient in whom it oc- 
curs. Rheumatism, unfortunately, does tend to " run 
in families." Apparently some peculiar susceptibility 
of the nervous system to influences which would be 
comparatively harmless to normal nerves and cells 
is capable of being inherited. But this inheritance is 
almost invariably " recessive," in Mendelian terms, 
and a majority of the children of even the most rheu- 
matic parent may entirely escape the disease, especially 
if they live rationally and vigorously, feed themselves 
abundantly, and avoid overwork and overcrowding. 



OUR principal dread of a wound is from fear that 
it may fester instead of healing quickly. We don't 
exactly enjoy being shot, or stabbed, or scratched , though, 
as a matter of fact, in what Mulvaney calls the "fog 
av fightin"' we hardly notice such trifles unless im- 
mediately disabling. But our greatest fear after the 
bleeding has stopped is lest blood-poisoning may set 
in. And we do well to dread it, for in the olden days, 
that is, barely fifty years ago, in wounds of any size 
or seriousness, two-thirds of the risk remained to be 
run after the bleeding had been stopped and the band- 
ages put on. Nowadays the danger is only a fraction of 
one per cent, but till half a century ago every wound 
was expected to form "matter" or pus in the process 
of healing, as a matter of course. Most of us can recall 
the favorite and brilliant repartee of our boyhood days 
in answer to the inquisitive query, " What's the mat- 
ter ? " " Nuthin' : it has n't come to matter yet. It's 
only a fresh cut ! " 

Even surgeons thought it a necessary part of the pro- 
cess of healing, and the approving term " laudable pus " 
was applied to a soft, creamy discharge, without either 
offensive odor or tinge of blood, upon the surfaces of the 
healing wound; and the hospital records of that day 


noted with satisfaction that, after an operation, "sup- 
puration was established." So strongly was this idea 
intrenched, that a free discharge or outpouring of some 
sort was necessary to the proper healing of the wound, 
that in the Middle Ages it was regarded as exceedingly 
dangerous to permit wounds to close too quickly. 
Wounds that had partially united were actually torn 
apart, and liquids like oil and wine and strong acids, 
which tended to keep them from closing and to set up 
suppuration, were actually poured into them; and in 
some instances their sides were actually burned with 
hot irons. There was a solid basis of reason under- 
lying even these extraordinary methods, viz., the " rule 
of thumb " observation, handed down from one gener- 
ation to another, that wounds that discharged freely 
and " sweetly," while they were slow in healing and 
left disfiguring scars, usually did not give rise to serious 
or fatal attacks of blood-poison or wound-fever. And 
of two evils they chose the less. Plenty of pus and a big 
ugly scar in preference to an attack of dangerous blood- 
poisoning. Even if it did n't kill you, it might easily 
cripple you for life by involving a joint. The trouble 
was with their logic, or rather with their premises. 
They were firmly convinced that the danger came from 
ivithin, that there was a sort of morbid humor which 
must be allowed to escape, or it would be dammed up 
in the system with disastrous results. 

One day a brilliant skeptic by the name of Lister 
(who is still living) took it into his head that perhaps 
the fathers of surgery and their generations of imitators 
might have been wrong. He tried the experiment, shut 


germs out of his wounds, and behold, antiseptic sur- 
gery, with all its magnificent line of triumphs, was born ! 

Now a single drop of pus in an operation wound is 
as deep a disgrace as a bedbug on the pillow of a model 
housekeeper, and calls for as vigorous an overhauling 
of equipment, from cellar to skylight; while a second 
drop means a commission of inquiry and a drumhead 
court-martial. This is the secret of the advances of 
modern surgery, not that our surgeons are any more 
skillful with the knife, but that they can enter cavities 
like those of the skull, the spinal cord, the abdomen, 
and the chest, remove what is necessary, and get out 
again with almost perfect safety ; whereas these cavities 
were absolutely forbidden ground to their forefathers, 
on account of the twenty, forty, yes, seventy per cent 
death risk from suppuration and blood-poison. 

The triumphs of antisepsis and asepsis, or keeping 
the " bugs " out of the cuts, have been illustrated scores 
of times already by abler pens, and are a household 
word, but certain of its practical appliances in the 
wounds and scratches and trifling injuries of every-day 
life are not yet so thoroughly familiar as they should 
be. When once we know who our wound-enemies are, 
whence they came, and how they are carried, the fate 
of the battle is practically in our own hands. 

Like most disease-germs our wound-infection foes 
are literally " they of our own household." They don't 
pounce down upon us from the trees, or lie in wait for 
us in the thickets, or creep in the grass, or grow in the 
soil, or swarm in our food. They live and can live 
only within the shelter of our own bodies, where it is 


warm and moist and comfortable. This is one great (in 
the expressive vernacular) " cinch " that we have on 
the vast majority of disease-germs, whether medical 
or surgical, that they do not flourish and breed outside 
of the body, or of houses closed and warm; and this 
grip can be improved, with skill and determination, 
into a veritable strangle-hold on most of them. In the 
language of biology, most of them have become 
"adapted to their environment" so closely that they 
can scarcely flourish and breed anywhere outside of the 
warm, moist, fertile soil of a living body, and many 
of them cannot even live long at temperatures more 
than ten degrees above or fifteen degrees below that 
of the body. At all events, so poorly are these pus- 
germs able to preserve their vigor and power of attack, 
not merely outside of the human body, but outside of 
some wound or sore spot, that it is practically certain 
that eight-tenths of all cases of wound-infection or 
blood-poisoning come directly from some previous 
festering wound, sore, ulcer, scab, boil, or pimple, in or 
on some other human being or animal. Practically 
whenever we get pus in a wound in a hospital, we 
insist upon finding the precise previous case of pus 
from which that originated, and seldom is our search 
unsuccessful. If we kept not only our wounds surgically 
clean, but our gums, noses, throats, skins, and finger- 
nails, and burned and sterilized everything that came 
in contact with a sore, pustule, or scab, we should wipe 
out nine-tenths of our cases of wound-infection and 
suppuration; in fact, practically all of them, except 
such small percentage as may come from contact with 


infections in animals. This is the reason why, up to 
half a century ago, by a strange paradox hospitals were 
among the most dangerous places to perform opera- 
tions in, on account of the abundance of wounds or 
sores always present for the pus-germs to breed in, 
and the fact that out of fifty or more wound-cases, 
there was practically certain to be one or two infected 
ones to poison the whole lot. 

Surgeons, ignorant of antisepsis, and careless nurses, 
spread the infection along, until in some instances it 
reached a virulence which burst into the dreaded 
" hospital gangrene." This dread disease was the 
scourge of all hospitals, especially military ones, all 
over the civilized world, as recently as our War of Se- 
cession. In some wards of our military hospitals, from 
thirty to fifty per cent of all the wounded received were 
attacked, and over five thousand cases were formally 
reported during the war, of which nearly fifty per cent 
died. This plague was born solely of those two great 
mothers of evils, ignorance and dirt, and is to-day, in 
civilized lands, as extinct as the dodo. Then the dread 
that the community had of hospitals, as places that 
" help the poor to die," in Browning's phrase, had a 
certain amount of foundation ; and cases operated upon 
in a farmhouse kitchen, where no one in the family 
happened to have had a boil or a catarrh or a fester- 
ing cut within a month or so, and where the knife hap- 
pened to be clean or new, would recover with less sup- 
puration than hospital cases. Nowadays, from inces- 
sant and eternal vigilance, a hospital is surgically the 
cleanest and safest place in the world for an operation, 


so that most surgeons decline to operate outside of 
one, except in emergencies; and some will not even 
operate except in one with which they are personally 
connected, so that they know every step in the process 
of protection. 

It was this terrible risk of the surgeon carrying 
infection from one case to another, that made the coro- 
ner of London declare, barely sixty years ago, that he 
would hold an inquest upon the next case of death after 
ovariotomy that was reported to him, on account of 
the fearful pus-mortality that followed this serious 
operation, which now has a possible death-rate from 
all causes connected with the operation of only a frac- 
tion of one per cent. 

The brusque reply is still remembered ofLawson 
Tait, the great English ovariotomist, to a distinguished 
German colleague, who had inquired the secret of his 
then marvelously low death-rate : after a glance at the 
bands of mourning on the ends of the other's fingers, he 
said, " I keep my finger-nails clean, sir ! " There was 
sadly too much truth in the saying of another eminent 
surgeon, that in the pre-Listerian days many a poor 
woman's death warrant was written under the finger- 
nails of her surgeon. This reproach has been wiped 
out, thank Heaven! but the labor, pains, and persist- 
ence after heart-breaking failures which it took to do 
it ! Never was there a more vivid illustration of the 
declaration that genius is the capacity for taking pains, 
than antiseptic surgery ! Not a loophole must be left 
unstopped, not a possibility unconsidered, not a thing 
in, or about, or connected with, the operating-room left 


unsterilized, except the patient and the surgeon; 
and these are brought as near to it as is possible 
without danger to life. 

In the first place, the operating-room itself must be 
like a bath room, or, more accurately, the inside of a 
cistern. Walls, floor, and ceiling are all waterproof and 
capable of being washed down with a hose. There must 
be no casings or cornices of any sort to catch dust; 
and in the best appointed hospitals no one is per- 
mitted to enter, under any pretext, whose hands and 
garments have not been sterilized. 

In the second place, everything that is brought into 
the room for use in, "or during, the operation, is first 
thoroughly sterilized. The knives, instruments, and 
other operative objects are sterilized by boiling, or by 
the use of superheated steam ; and the towels, dressings, 
bandages, sheets, etc., by boiling, baking, or super- 
heated steam. Then begins the preparation of the sur- 
geon and the nurse. Dressing-rooms are provided, in 
which the outer garments are removed, and the hands 
given an ordinary wash. Then the scrubbing-room is 
entered, where, at a series of basins provided with 
running hot and cold water, whose faucets are turned 
by pressure with the foot so as to avoid any necessity 
for touching them with the hand, the hands are 
thoroughly scrubbed with hot water, boiled soap, and 
a boiled nail-brush. Then they are plunged into, and 
thoroughly soaked in, some strong antiseptic solution, 
then washed again; then plunged into another anti- 
septic solution, containing some fat solvent like ether 
or alcohol, to wash off any dirt that may have been pro- 


tected by the natural oil of the skin. Then they are 
thoroughly scrubbed with soap and hot water again, to 
remove all traces of the antiseptics, most of which are 
irritating to wounded tissues ; then washed in absolute 
alcohol, then in boiled or distilled water. Then the 
nurse, whose hands are already sterilized, takes out 
of the original package in which it came from the 
sterilizing oven, a linen surgical gown or suit which 
covers the operator from neck to toes. A sterilized 
linen or cotton cap is placed upon his head and pulled 
down so that the scales or germs of any sort may not 
fall into the wound. Some surgeons of stout and com- 
fortable habit, who are apt to perspire in the high tem- 
perature of an operating-room, will tie a band of gauze 
around their foreheads, to prevent any unexpected 
drops of perspiration from falling into the wound; 
while some purists muffle up the mouth and lower part 
of the face lightly in a similar comforter. 

You would think that by this time the hands were 
clean enough to go anywhere with safety, but no risks 
are going to be taken. A pair of rubber or cotton 
gloves, the former taken right out of a strong antiseptic 
solution, the latter out of the sterilizing oven, are pulled 
carefully on by the nurse. Holding his sacred hands 
spread out rigidly before him, like the front paws of 
a kangaroo, the surgeon carefully edges his way into the 
operating-room, waiting for any doors that he may have 
to pass through to be opened by the nurse, or awk- 
wardly pushing them with his elbow. In that attitude 
of benediction, the hands are maintained until the 
operation is ready to begin. 


Then comes the patient ! If his condition will in any 
wise permit, he has been given a boiling hot bath and 
scrub the night before, and put to bed in a sterilized 
nightgown between sterilized sheets. The region 
which is to be operated upon has, at the same time, 
been scrubbed and rubbed and flushed with hot water, 
germicides, alcohol, soap, in fact, has gone through 
the same sacred ceremonial of cleansing through which 
the surgeons' hands have passed ; and a large, closely 
fitting antiseptic dressing, covering the whole field, has 
been applied and tightly bound. He is brought into a 
waiting-room and put under ether by an anaesthetist, 
through a sterilized mask ; he is then wheeled into the 
operating-room, the dressing is removed, a thorough 
double scrub is again given, for " good measure," to 
the whole area in which the wound is to be made. A 
big sheet is thrown over the lower part of his body, 
another over the upper part, a third, with an oval open- 
ing in the centre of it, thrown over the region to be 
operated upon. The instrument nurse takes a boiled 
knife out of a sterilized dish of distilled water, hands it 
to the surgeon, who takes it in his gloved hand, and the 
operation begins. 

Now, if you can think of any possible chink through 
which a wandering streptococcus can, by any possi- 
bility, sneak into that wound, please suggest it, and it 
shall be closed immediately ! 

The intruders against whom all these preparations 
are made are two in number: Streptococcus pyogenes 
and Staphylococcus pyogenes cousins, as you see, 
by their names. Their last (not family) name really 


means something, and is not half so alarming as it 
sounds, as it is Greek for " pus-making." Their 
real family name, Coccus, which means a berry, was 
suggested, by their rounded shape under the micro- 
scope, to some poetically minded microscopist. Unde- 
sirable citizens, both of them ! But the older, or Strepto, 
cousin is by far the more dangerous character and des- 
perate individual, giving rise to and being concerned in 
nearly all the civilized and dangerous wound-fevers 
septicaemia, erysipelas, etc. Staphylococcus is a milder 
and less harmful individual, seldom going farther than 
to produce the milder forms of festering, discharging, 
refusing to heal, pustules, etc. He is not to be given a 
yard of leeway, however, for if he can get a sufficient 
number of dirty wounds to run through, he can work 
himself up to a high degree of virulence and poisoning 
power. Indeed, this faculty of his may possibly furnish 
a clew as to how these pus-makers developed their power 
of living in wounds, and almost nowhere else. There 
is another cousin also, in the group, called Staphy- 
lococcus pyogenes albus, to distinguish him (albus, 
" white ") from the other two, who have the tag name 
aureus (golden). He is an almost harmless denizen 
of the surfaces of our bodies, particularly the mouths 
of the sweat-ducts, and the openings of the hair folli- 
cles. Under peculiarly favorable circumstances, such 
as a very big wound, an aggravated chafe, or the ap- 
plication of that champion " bug-breeder," a poul- 
tice, he may summon up courage enough to attack 
some half-dead skin-cells and make a few drops of 
pus on his own account. He is the criminal concerned 


in the so-called stitch-abscesses, or tiny points of pus 
which form around the stitches of a big wound and 
in some of the smaller pimples which turn to " matter." 
It is conceivable that this feeble and harmless white 
coccus may at some time have been accelerated under 
favorable circumstances' to where he was endowed 
with "yellow" powers, and even, upon another turn 
of the screw, with strepto-virulence. But this is a 
mere academic question. Practically the only thing 
needful is to keep all the rascals out of every wound. 
Now comes the question, how is this to be done ? 
Fortunately it is not necessary to hunt out and destroy 
the pus-germs in their breeding-places outside of the 
human body. As we have seen, they do not long retain 
their vitality out of doors, or as a rule even in the dust 
of rooms and dirt of houses, unless the latter have been 
recently contaminated with the dressings of, or dis- 
charges from, wounds. There are two main things to 
be watched: first, the wound itself, and second, any 
unwashed or unsterilized part of your own or some 
other living body. Dirt of all sorts is a mighty good 
thing to keep absolutely out of the wound, but prac- 
tically a whole handful of ordinary soil or dust rubbed 
into a wound might not, unless it happened to contain 
fertilizer of some sort, be half so dangerous as a single 
touch with a finger which had been dressing a wound, 
picking a scab out of the nose, rubbing an ulcerated 
gum, or scratching an itching scalp. If it be a cut on 
the finger, or scratch on the hand, for instance, don't 
suck it, or lick it, unless you can give an absolutely 
clean bill of health to your gums and teeth. If not 


thoroughly brushed three or four times a day, they are 
sure to be swarming with germs of twenty or thirty 
different species, which not infrequently include one 
or both of the pus-germs. Indeed, the real reason why 
the bite of certain animals, and above all of a man, 
particularly of a " blue-gum nigger," is regarded as so 
dangerous is on account of the swarms of germs that 
breed in any remnants of food left between the teeth 
or in the pockets of ulcerating gums. Many a human 
bite is almost as dangerous as a rattlesnake's. The 
devoted hero who sucks the poison of the dagger out 
of the wound may be conferring a doubtful benefit, if 
he happens to be suffering from Rigg's disease. 

Don't try to stop the bleeding unless it comes in 
spurts or the flow is serious. The loss of a few tea- 
spoonfuls, tablespoonfuls, or, for the matter of that, 
cupfuls, of blood won't do you any harm, and its free 
flow will wash out the cut from the bottom, and carry 
out most of the germs that may happen to be present 
on the knife or nail. If water and dressings are not 
accessible, let the blood cake and dry over the wound 
without disturbing it, even though it does look rather 

A slight cut with a clean knife, or other instrument, 
into which no dirt has been rubbed, will often require 
no other dressing than its own blood-scab. If, however, 
as oftener happens, you cannot be sure of the cleanness 
of the knife, tool, or nail, hold the wound under running 
water from a pump or tap (this is not germ-free, but 
practically never contains pus-germs) , until the wound 
has been thoroughly washed out, wiping any gravel 


or dirt out of the cut with soft rags which have been 
recently washed, or baked in the oven; then dry with 
a small piece of linen, or white goods, put on a dressing 
of absorbent cotton such as can be purchased for a few 
cents an ounce at any drug store. Absorbent or surgi- 
cal cotton makes a good dressing, because it both sucks 
up any fluids which might leak out of the wound, and 
forms a mesh-filter through which no germs can pene- 

It is not advisable to use sticking-plaster for any but 
the most trivial wounds, and seldom even for these, 
for several reasons. First, because its application usu- 
ally involves licking itlo make it stick; second, because 
it must cover a sufficient amount of skin on either side 
of the wound to give it firm grip, and this area of skin 
contains a considerable number of both sweat-ducts 
and hair-follicles, which will keep on discharging under 
the plaster, producing a moist and unhealthy condition 
of the lips of the wound. Moreover, these sweat-ducts 
and hair-follicles will, as we have seen, frequently con- 
tain white staphylococci, which are at times capable of 
setting up a low grade of inflammation in the wound. 
A wound always heals better if its surfaces and 
coverings can be kept dry. This is why cotton makes 
such an ideal dressing, since it permits the free evap- 
oration of moisture, a moderate access of air, and yet 
keeps out all germs. 

If the cut or scratch is of any depth or seriousness 
whatever, or the knife, tool, or other instrument be 
dirty, or if any considerable amount of street-dust or 
garden-soil has got into the wound, then it is, by all 


means, advisable to go to a physician, have the wound 
thoroughly cleaned on antiseptic principles, and put up 
in antiseptic dressing. A single treatment of this sort, 
in a comparatively trifling wound which has become 
in any way contaminated, may save weeks of suffer- 
ing and disability, and often danger of life, and will in 
eight cases out of ten shorten the time of healing from 
forty to sixty per cent. The rapidity with which a 
wound in a reasonably healthy individual, cleaned 
and dressed on modern surgical principles, will heal, 
is almost incredible, until it has actually been seen. 

The principal danger of garden-soil or street-dust 
in a wound is not so much from pus-germs, though 
these may be present, as from another " bug " the 
tetanus or lockjaw bacillus. This deadly organism 
lives in the alimentary canal of the horse, and hence 
is to be found in any dirt or soil which contains horse 
manure. It is, fortunately, not very common, or 
widely spread, but enough so to make it the part of 
prudence to have thoroughly asepticized and dressed 
any wound into which considerable amounts of garden- 
soil, or street-dust, have been rubbed. The reason 
why wounds of the feet and hands have had such 
a bad reputation, both for festering and giving rise 
to lockjaw, is that it is precisely in these situations 
that they are most likely to get garden-soil, or stable 
manure, into them. The classic rusty nail does not de- 
serve the bad reputation as a wound-maker which it 
enjoys, its bad odor being chiefly due to the fact al- 
ready referred to, that injuries inflicted by it are most 
apt to be in the palm of the hand, or in the sole of the 


foot, and hence peculiarly liable to contamination by 
the tetanus and other soil bacilli. 

For some reason or other which we don't as yet thor- 
oughly understand, burns from a toy pistol in particular, 
and Fourth of July fireworks in general, seem to be 
peculiarly liable to be followed by tetanus. The ful- 
minate used in the cap of a toy pistol, and the paper 
and explosives of several of the brands of firecrackers, 
have been thoroughly examined bacteriologically, but 
without finding any tetanus germs in them. So many 
cases of lockjaw used to follow the Fourth of July 
celebrations a few years ago, that Boards of Health be- 
came alarmed, and not only forbade outright the sale 
of deadly toy pistols, but provided supplies of the teta- 
nus antitoxin at various depots throughout the cities, 
so that all patriotic wounds of this description could 
have it dropped into them when they were dressed. 
Since then, the lockjaw penalty which we pay for 
our highly intelligent method of celebrating the Fourth, 
has diminished considerably. It is probable that the 
mortality was chiefly due to infection of the ugly, slow- 
healing, dirty little wounds with city-dust, a large per- 
centage of which, of course, is dried horse manure. 
What with the tetanus bacillus and the swarms of flies 
which breed chiefly in stable manure, and carry 
summer diseases, typhoid, diphtheria, and tuberculo- 
sis in every direction, it will not be long before the 
keeping of horses within city limits will be as strictly 
forbidden as pigpens now are. 

So definite is the connection between the tetanus 
bacilli and the soil, that tetanus fields or lockjaw gar- 


dens are now recognized and listed by the health 
authorities, on account of their having given rise to 
several successive cases of the disease. Workers in 
such fields or gardens, who scratch or cut themselves, 
are warned to report themselves promptly for treat- 
ment with the tetanus antitoxin. 

Apart from the tetanus germ, however, the problem 
of the treatment of wounds while there should be 
perfect cleanliness, the spotlessness of the model house- 
keeper multiplied fivefold is yet not so much a 
matter of keeping dirt in general out of the wound, as 
of keeping out that particular form of dirt which con- 
sists of, or contains, discharges from some previous 
wound, sore, ulcer, or boil! 

While both these pus-organisms can breed and 
flourish freely only in wounds or sores, this is but their 
starting-point where they gather strength to invade 
the entire organism. We used to make a distinction 
between those cases in which their toxins or poison- 
products got into the blood, with the production of 
fever, headache, backache, delirium, sweats, etc., 
which we term septicaemia, and other cases in which 
the cocci themselves were carried into the blood and 
swept all over the body by forming fresh foci, or breed- 
ing-places, which resulted in abscesses all over the 
body, which we call pyaemia. But now we know that 
there is no hard and fast line to be drawn, and that 
the germs get into the blood much more easily than 
we supposed ; and the degree and dangerousness of the 
fever which they set up depend, first, upon their viru- 
lence, or poisonousness, and, second, upon the resisting 


power of the patient at the time. Anything which lowers 
the general health and strength and weakens the re- 
sisting power of the body will make it much easier for 
pus-germs to get an entrance into it, and overwhelm 
it; so that, after prolonged famines for instance, or 
among the population of besieged cities, or in armies 
or exploring expeditions which have been deprived of 
food and exposed to great hardship, the merest scratch 
will fester and inflame, and give rise to a serious and 
even fatal attack of blood-poisoning, erysipelas, hos- 
pital gangrene, etc. Famines and sieges in fact are not 
infrequently followed by positive epidemics of blood- 
poisoning, often in exceedingly severe and fatal forms. 

It was long ago noted by the chroniclers that the 
death-rate from wound-fever among the soldiers of a 
defeated army was apt to be much greater than among 
those of the victorious one, and this was quoted as one 
of the stock evidences of the influence of mind over 
body. But we now know that armies are not beaten 
without some physical cause, that the defeated soldiers 
are apt to be in poorer physical condition to begin 
with ; that they have often been cut off from their base 
of supplies, have made desperate forced marches 
without food or shelter in the course of their retreat ; 
and, until within comparatively recent years, were 
never half so well treated or well fed as their cap- 

As the invading germs pass into the body, they travel 
most commonly through the lymph-channels and skin ; 
are arrested and threatened with destruction by the so- 
called lymphatic glands, or lymph-nodes. This is why, 


if you have a festering wound or boil on your hand or 
wrist, the " kernels " or lymph-nodes up in your 
armpit will swell and become painful. If the lymph- 
nodes can conquer the germs and eat them up, the 
swelling goes down and the pain disappears. But if 
the germs, on the other hand, succeed in poisoning and 
killing the cells of the body, these latter melt down and 
turn to pus, and we get what we call a " secondary 

The next commonest point of attack of these pus- 
germs, if they once get into the body, and by far the 
most dangerous, is the heart, as in rheumatism and other 
fevers. Some will also attack the kidneys, giving rise 
to albumin in the urine, while others attack the mem- 
branes of the joints (synovia) and cause suppuration 
of one or more joints in the body, which is very apt to 
be followed by very serious stiffening or crippling. So 
that, common, and, in many instances, comparatively 
mild as they are, the pus-germs in the aggregate are 
responsible for a very large amount of damage to the 
human body. 

This is the way the streptococcus and staphylococcus 
behave in an open wound, or sore; but they have two 
other methods of operating which are somewhat special 
and peculiar. One of these is where the germ digs and 
burrows, as it were, underground, in a limited space, 
resulting in that charming product known as a boil, or a 
carbuncle. The other, where it spreads rapidly over 
the surface just under the skin, after the fashion of 
the prairie fire, producing erysipelas. In the first of 
these he behaves like the famous burrowing owl of our 


Western plains, who forms, with the prairie-dog, the so- 
called "happy family." He never makes his own bur- 
row, he simply uses one which is already provided for 
him by nature, and that is the little close-fitting pouch 
surrounding the root of a hair. Whether the criminal 
is a harmless native white coccus which has suddenly 
developed anti-social tendencies, or a Mongolian im- 
migrant who has been accidentally introduced, is still 
an open question. The probabilities are that it is more 
frequently the latter, as, while boils are absolutely no 
respecters, either of persons or places, and may rear 
their horrid heads in every possible region of the hu- 
man form divine, yef they display a very decided ten- 
dency to appear most frequently in regions like the back 
of the neck, the wrist, the hips, and the nose. One 
thing that these areas have in common is that they are 
liable to a considerable amount of chafing and scratch- 
ing as by collars and stocks on the neck, and cuffs on 
the wrists, or of friction from belts, or pressure or chaf- 
ing from chairs or saddles. When the tissues have 
been bruised or chafed after such fashion, especially 
if the surface of the skin has been at the same time 
broken, and any pus-organism is either present in the 
hair-follicle, like the white coccus, or rubbed into it 
by a finger or finger-nail which has just been sucked 
in the mouth, used to pick the nose, or possibly en- 
gaged in dressing some wound, or cutting meat, or 
handling fertilizer, then all the materials for an ex- 
plosion are at hand. 



THE imagination of the race has ever endowed 
Cancer with a peculiar individuality of its own. 
Although it has vaguely personified in darkest ages 
other diseases, like the Plague, the Pestilence, and 
Maya (the Smallpox), these have rapidly faded away 
in even the earliest light of civilization, and have never 
approached in concreteness and definiteness the ma- 
levolent personality of Cancer. Its sudden appearance, 
the utter absence of any discoverable cause, the twinges 
of agonizing pain that shoot out from it in all directions, 
its stone-like hardness in the soft, elastic flesh of the 
body, the ruthless way in which it eats into and destroys 
every organ and tissue that come in its way, make this 
impression, not merely of personality, but of positive 
malevolence, almost unescapable. 

Its very name is instinct and bristling with this idea : 
Krebs, in German, Cancer, in Latin, French, and Eng- 
lish, Carcinoma, in Greek, all alike mean " Crab," a 
ghastly, flesh-eating parasite, gnawing its way into the 
body. The simile is sufficiently obvious. The hard 
mass is the body of the beast; the pain of the growth 
is due to his bite ; the hard ridges of scar tissue which 
radiate in all directions into the surrounding skin are 
his claws. 

The singular thing is that, while brushing aside, of 


course, all these grotesque similes, the most advanced 
researches of science are developing more and more 
clearly the conception of the independent individuality 
as they term it, the autonomy of cancer. 

More and more decidedly are they drifting toward the 
unwelcome conclusion that in cancer we have to deal 
with a process of revolt of a part of the body against 
the remainder, " a rebellion of the cells," as an eminent 
surgeon-philosopher terms it. Unwelcome, because a 
man's worst foes are " they of his own household." 
Successful and even invigorating warfare can be waged 
against enemies without, but a contest with traitors 
within dulls the spear and paralyzes the arm. Against 
the frankly foreign epidemic enemies of the race a 
sturdy and, of late years, a highly successful battle 
has been fought. We have banished the plague, drawn 
the teeth of smallpox, riddled the armor of diphtheria, 
and robbed consumption of half its terrors. In spite 
of the ravings and gallery-play of the Lombroso school 
anent " degeneracy," our bills of mortality show a 
marked diminution in the fatality of almost every 
important disease of external origin which afflicts hu- 

The world-riddle of pathology the past twenty years 
has been : Is cancer due to the invasion of a parasite, a 
veritable microscopic crab, or is it due to alterations in 
the communal relations, or, to speak metaphorically, 
the allegiance of the cells ? Disappointing as it may be, 
the balance of proof and the opinion of the ablest 
and broadest-minded experts are against the parasitic 
theory, so far, and becoming more decidedly so. In 


other words, cancer appears to be an evil which the 
body breeds within itself. 

There is absolutely no adequate ground for the tone 
of lamentation and the Cassandra-like prophecy which 
pervade all popular, and a considerable part of medi- 
cal, discussion of the race aspects of the cancer prob- 
lem. The reasoning of most of these Jeremiahs is 
something on this wise : That, inasmuch as the deaths 
from cancer have apparently nearly trebled in propor- 
tion to the population within the last thirty years, it 
only needs a piece of paper and a pencil to be able to 
figure out with absolute certainty that in a certain 
number of decades, at this geometric ratio, there will 
be more deaths from cancer than there are human be- 
ings living. 

There could be no more striking illustration, both of 
the dangerousness of "a little knowledge" and of the 
absurdity of applying rigid logic to premises which con- 
tain a large percentage of error. Too blind a confidence 
in the inerrancy of logic is almost as dangerous as super- 
stition. Space will not permit us to enter into details, 
but suffice it to say : 

First, that expert statisticians are in grave doubt 
whether this increase is real or only apparent, due to 
more accurate diagnosis and more complete recording 
of all cases occurring. Certainly a large proportion of 
it is due to the gross imperfection of our records thirty 
years ago. 

Second, that the apparent increase is little greater 
than that of deaths due to other diseases of later life, 
such as nervous, kidney, and heart diseases. Our heavi- 


est saving of life so far is in the first five-year period, 
and more children are surviving to reach the cancer 
and Bright 's disease age. 

Third, that a disease, eighty per cent of whose death- 
rate occurs after forty-five years of age, is scarcely 
likely to threaten the continued existence of the race. 

The nature of the process is a revolt of a group of 
cells. The cause of it is legion, for it embraces any in- 
fluence which may detach the cell from its normal sur- 
roundings, " isolate it," as one pathologist expresses 
it. The cure is early and complete amputation of not 
only the rebellious cells, but of the entire organ or re- 
gion in which they occur. 

A cancer is a biologic anomaly. Everywhere else in 
the cell-state we find each organ, each part, strictly sub- 
ordinated, both in form and function, to the interests 
of the whole. 

Here this relation is utterly disregarded. In the 
body-republic, where we have come to regard harmony 
and loyalty as the invariable rule, we find ourselves 
suddenly confronted by anarchy and revolt. 

The process begins in one great class of cells, the 
epithelium of the secreting glands. This is a group of 
cell-citizens of the highest rank, descended originally 
from the great primitive skin-sheet, which have formed 
themselves into chemical laboratories, ferment-facto- 
ries for the production of the various secretions required 
by the body, from the simplest watery mucus, as in the 
mouth, or the mere lubricant, as in the fat-glands of the 
hair-follicles, to the most complex gastric or pancreatic 
juice. They form one of the most active and import- 


ant groups in the body, and their revolt is dangerous 
in proportion. 

The movement of the process is usually somewhat 
upon this order: After forty, fifty, or even sixty years 
of loyal service, the cells lining one of the tubules of a 
gland for instance, of the lip, or tongue, or stomach 
- begin to grow and increase in number. Soon they 
block up the gland-tube, then begin to push out in the 
form of finger- or root-like columns of cells into the 
surrounding tissues. 

These columns appear to have the curious power of 
either turning their natural digestive ferments against 
the surrounding tissues, or secreting new ferments for 
the purpose, closely resembling pepsin, and thus literally 
eating their way into them. So rapidly do these cells 
continue to breed and grow and spread resistlessly in 
every direction, that soon the entire gland, and next 
the neighboring tissues, become packed and swollen, 
so that a hard lump is formed, the pressure upon the 
nerve-trunks gives rise to shooting pains, and the first 
act of the drama is complete. 

But these new columns and masses, like most other 
results of such rapid cell-breeding in the body, are liter- 
ally a mushroom growth. Scarcely are they formed 
before they begin to break down, with various results. 
If they lie near a surface, either external or internal, 
they crumble under the slightest pressure or irritation, 
and an ulcer is formed, which may either spread slowly 
over the surface, from the size of a shilling to that of a 
dinner-plate, or deepen so rapidly as to destroy the 
entire organ, or perforate a blood-vessel and cause 


death by hemorrhage. The cancer is breaking down 
in its centre, while it continues to grow and spread at 
its edge. Truly a " magnificent scheme of decay." 

Then comes the last and strangest act of this weird 
tragedy. In the course of the resistless onward march 
of these rebel cell-columns some of their skirmishers 
push through the wall of a lymph-channel, or even, 
by some rare chance, a vein, and are swept away by the 
stream. Surely now the regular leucocyte cavalry have 
them at their mercy, and can cut them down at leisure. 
We little realize the fiendish resourcefulness of the 
cancer-cell. One such adrift in the body is like a ferret 
in a rabbit warren ; rfo other cell can face it for an instant. 
It simply floats unmolested along the lymph-channels 
until its progress is arrested in some way, when it 
promptly settles down wherever it may happen to have 
landed, begins to multiply and push out columns in every 
direction, into and at the expense of the surrounding 
tissues, and behold, a new cancer, or " secondary 
nodule," is born (metastasis). 

In fact, it is a genuine "animal spore," or seed-cell, 
capable of taking root and reproducing its kind in any 
favorable soil; and, unfortunately, almost every inch 
of a cancer patient's body seems to be such. It is merely 
a question of where the spore-cells happen to drift and 
lodge. The lymph-nodes or " settling basins" of the 
drainage area of the primary cancer are the first to be- 
come infected, probably in an attempt to check the in- 
vaders ; but the spores soon force their way past them 
toward the central citadels of the body, and, one after 
another, the great, vital organs the liver, the lungs, 


the spleen, the brain are riddled by the deadly 
columns and choked by decaying masses of new cells, 
until the functions of one of them are so seriously in- 
terfered with that death results. 

Obviously, this is a totally different process, not 
merely in degree, but in kind, from anything that takes 
place as a result of the invasion of the body by an in- 
fectious germ or parasite of any sort. There is a certain 
delusive similarity between the cancer process and an 
infection. But the more closely and carefully this simi- 
larity is examined the more superficial and unreal does 
it become. The invading germ may multiply chiefly 
at one point or focus, like cancer, and from this spread 
throughout the body and form new foci, and may even 
produce swarms of masses of cells resembling tumors, 
as, for instance, in tuberculosis and syphilis. But here 
the analogy ends. 

The great fundamental difference between cancer 
and any infection lies in the fact that, in an infection, 
the inflammations and poisonings and local swellings 
are due solely and invariably to the presence and 
multiplication of the invading germs, which may be 
recovered in millions from every organ and region 
affected, while swellings or new masses produced are 
merely the outpouring of the body-cells in an attempt 
to attack and overwhelm these invaders. In cancer, 
on the contrary, the destroying organism is a group of 
perverted body-cells. The invasion of other parts of 
the body is carried out by transference of their bastard 
and abortive offspring. Most significant of all, the new 
growths and swellings that are formed in other parts 


of the body are composed, not of the outpourings of the 
local tissues, but of the descendants of tliese pirate cells. 
This is one of the most singular and incredible things 
about the cancer process : that a cancer starting, say, 
in the pancreas, and spreading to the brain, will there 
pile up a mass not of brain-cells, or even of connec- 
tive tissue-cells but of gland-cells, resembling crudely 
the organ in which it was born. So far will this resem- 
blance go that a secondary cancer of the pancreas found 
in the lung will yield on analysis large amounts of 
trypsin, the digestive ferment of the pancreas. Similarly 
a cancer of the rectum, invading the liver, will there 
pile up in the midst of the liver-tissue abortive attempts 
at building up glands of intestinal mucous membrane. 

This fundamental and vital difference between the 
two processes is further illustrated by this fact : While 
an ordinary infection may be transferred from one in- 
dividual to another, not merely of the same species, but 
of half a dozen different species, with perfect certainty, 
and for any number of successive generations, no case 
of cancer has ever yet been known to be transferred 
from one human being to another. In other words, 
the cancer-cell appears utterly unable to live in any 
other body except the one in which it originated. 

So confident have surgeons and pathologists become 
of this that a score of instances are on record where 
physicians and pathologists, among them the famous 
surgeon-pathologist, Senn, of Chicago, only a few years 
ago, have voluntarily ingrafted portions of cancerous 
tissue from patients into their own arms, with absolutely 
no resulting growth. In fact, the cancer-cell behaves 


like every other cell of the normal body, in that, though 
portions of it can be grafted into appropriate places in 
the bodies of other human beings and live for a period 
of days, or even months, they ultimately are completely 
absorbed and disappear. The only apparent exception 
is the epithelium of the skin, which can be used in 
grafting or skinning over a wide raw surface in another 
individual. However, even here the probability appears 
to be that the taking root of the foreign cells is only 
temporary, and makes a preliminary covering or protec- 
tion for the surface until the patient's own skin-cells 
can multiply fast and far enough to take its place. 

A similarly reassuring result has been obtained in 
animals. Not a single authenticated case is on record 
of the transference of a human cancer to one of the lower 
animals; and of all the thousands and thousands of 
experiments that have been made in attempting to 
transfer cancers from one animal to another, only one 
variety of tumor with the microscopic appearance of 
cancer the so-called Jensen's tumor of mice has 
yet been found which can be transferred from one ani- 
mal to another. 

So we may absolutely disabuse our minds of the fear 
which some of our enthusiastic believers in the para- 
sitic theory of cancer have done much to foster, that 
there is any danger of cancer " spreading," like an in- 
fectious disease. Disastrous and gruesome as are the 
conditions produced by this disease, they are absolutely 
free from danger to those living with or caring for the 
unfortunate victim. In the hundreds of thousands of 
cases of cancers which have been treated, in private 


practice, in general hospitals, and in hospitals devoted 
exclusively to their care, not a single case is on record 
of the transference of the disease to a husband, wife, 
or child, nurse or medical attendant. So that the cancer 
problem, like the Kingdom of Heaven, is within us. 

This conclusion is further supported by the disap- 
pointing result of the magnificent crusade of research 
for the discovery of the cancer " parasite," whether 
vegetable or animal, which has been pursued with a 
splendid enthusiasm, industry, and ability by the best 
blood and brains of the pathological world for twenty 
years past. I say disappointing, because a positive 
result the discovery and identification of a parasite 
which causes cancer would be one of the greatest 
boons that could be granted to humanity ; not so much 
on account of the actual loss of life produced by the 
disease as for the agonies of apprehension engendered 
by the fact of the absolute remorselessness and blind- 
ness with which it may strike, and our comparative 
powerlessness to cure. So far the results have been dis- 
tressingly uniform and hopelessly negative. 

Scores, yes, hundreds, of different organisms have 
been discovered in and about cancerous growths, and 
announced by the proud discoverer as the cause of 
cancer. Not one of these, however, has stood the test 
of being able to produce a similiar growth by inocula- 
tion into another body ; and all which have been deemed 
worthy of a test-research by other investigators besides 
the paternal one have been found to be mere accidental 
contaminations, and present in a score of other dis- 
eases, or even in normal conditions. Many of them have 


been shown to be abnormal products of the cells of 
the body in the course of the cancer process, and some 
even such ludicrous misfits as impurities in the chemical 
reagents used, scrapings from the corks of bottles, 
dust from the air, or even air-bubbles. These "dis- 
coveries" have ranged the whole realm of unicellular 
life, bacilli, bacteria, spirilla, yeasts, moulds, pro- 
tozoa, yet the overwhelming judgment of broad- 
minded and reputable experts the world over is the 
Scotch verdict of "not proven"; and we are more and 
more coming to turn our attention to the other aspect of 
the problem, the factors which cause or condition 
this isolation and assumption of autonomy on the part 
of the cells. 

This is not by any means to say that there is no 
causative organism, and that this will not some day be 
discovered. Human knowledge is a blind and short- 
sighted thing at best, and it may be that some invading 
cell, which, from its' very similarity to the body-cells, 
has escaped our search, will one day be discovered. 
Nor will the investigators diminish one whit of their 
vigor and enthusiasm on account of their failure thus 

The most strikingly suggestive proof of the native- 
born character of cancer comes from two of its biologic 
characters. The first is that its habit of beginning 
with a mass formation, rapidly deploying into columns 
and driving its way into the tissues in a ghastly flying 
wedge, is simply a perfect imitation and repetition of 
the method by which glands are formed during the 
development of the body. The flat, or epithelial, cells 


of the lining of the stomach, for instance, begin to pile 
up in a little swarm, or mass, elongate into a column, 
push their way down into the deeper tissue, and then 
hollow out in their interior to form a tubular gland. 
The only thing that cancer lacks is the last step of form- 
ing a tube, and thereby becoming a servant of the body 
instead of a parasite upon it. 

Nor is this process confined to our embryonic or 
prenatal existence. Take any gland which has cause 
to increase in size during adult life, as, for instance, 
the mammary gland, in preparation for lactation, and 
you will find massing columns and nests of cells push- 
ing out into the surrounding tissue in all directions, 
in a way that is absolutely undistinguishable in its ear- 
lier stages from the formation of cancer. It is a fact 
of gruesome significance that the two organs the 
mammary gland and the uterus in which this pro- 
cess habitually takes place in adult life are the two 
most fatally liable to the attack of cancer. 

Another biologic character is even more striking and 
significant. A couple of years ago it was discovered by 
Murray and Bashford, of the English Imperial Cancer 
Research Commission, that the cells of cancer, in their 
swift and irregular reproduction, showed an unexpected 
peculiarity. In the simplest form of reproduction, one 
cell cutting itself in two to make two new ones, known 
as mitosis, the change begins in the nucleus, or kernel. 
This kernel splits itself up into a series of threads or 
loops, known as the chromosomes, half of which go 
into each of the daughter cells. When, however, sex 
is born and a male germ-cell unites with a female germ- 


cell to form a new organism, each cell proceeds, as the 
first step in the process, to get rid of half of these 
chromosomes, so that the new organism has precisely 
the normal number of chromosomes, half of which are 
derived from the father and the other half from the 
mother germ-cell. This, by the way, is the mechanical 
basis of heredity. 

It has been long known that the mitotic processes 
of cancer and the forming and dividing of the chromo- 
somes were riotous and irregular, like the rest of its 
growth. But it was reserved for these investigators to 
discover the extraordinary fact that the majority of 
dividing and multiplying cancer-cells had, instead of 
the normal number of chromosomes, exactly half the 
quota. In other words, they had resumed the powers 
of the germ, or sexual, cells from which the entire body 
was originally built up, and were, like them, capable 
of an indefinite amount of multiplication and repro- 
duction. How extraordinary and limitless this power 
is may be seen from the fact that a little group of cancer- 
cells grafted into a mouse to produce a Jensen tumor, 
from which a' graft is again taken and transplanted 
into another mouse, and so on, is capable, in a com- 
paratively few generations, of producing cancerous 
masses a thousand times the weight of the original 
mouse in which the tumor started ! 

In short, cancer-cells are obviously a small, isolated 
group of the body-cells, which in a ghastly fashion have 
found the fountain of perpetual youth, and can ride 
through and over the law-abiding citizens of the body- 
state with the primitive vigor of the dawn of life. 


This brings us to the most practical and important 
questions of the problem: What are the influences 
which condition this isolation and outlawry of the cells ? 
What can we do to prevent or suppress the rebellion ? 
To the first of these science can only return a tentative 
and approximate answer. The subject is beset with 
difficulties, chief among which is the fact that we are 
unable to produce the disease with certainty in ani- 
mals, with the single exception of the Jensen's tumors 
in mice referred to, nor is it transferred from one 
human being to another, so that we can make even 
an approximate gue^s at the precise time at, or condi- 
tions under, which the process began. 

Many theories have been advanced, but most investi- 
gators who have studied the problem in a broad-minded 
spirit are coming gradually to agree to this extent : 

First of all, that one of the most powerful influences 
conditioning this isolation and revolt of the cells is age, 
both of the individual and of the organ concerned. 
Not only does far the heaviest cancer mortality fall 
between the ages of forty-five and sixty, but the organs 
most frequently and severely attacked are those which 
between these years are beginning to lose their function 
and waste away. First and most striking, the mammary 
gland and the uterus in women, and the shriveling lips 
and tongue of elderly men. To put it metaphorically, 
the mammary gland and the uterus, after the change of 
life, the lip, after the decay of the teeth, have done their 
work, outlived their usefulness, and are being placed 
upon a starvation pension by a grateful country. 
Nineteen out of twenty accept the situation without 


protest and sink slowly to a mere vegetative state of 
existence, but, in the twentieth, some little knot of cells 
rebel, revert to an ancestral power of breeding rapidly 
to escape extinction, begin to make ravages, and can- 
cer is born. 

The age-preferences are well marked. Cancer is 
emphatically a disease of senility, of age; but, as 
Roger Williams has pointed out in his admirable 
monograph, not of " completed " senility. 

To express it in percentages, barely twenty per cent 
of the cases occur before forty years of age, sixty per 
cent between forty and sixty, and twenty per cent 
between sixty and eighty. Thus the early period of 
decline, the transition stage between full functional 
vigor and declared atrophy (wasting) of the glands, 
is clearly the period of greatest danger; precisely the 
period in which the gland-cells, though losing their 
function, and income, have still the strength to in- 
augurate a rebellion, and a sufficient supply of the 
sinews of war, either in their own possession or within 
easy striking distance in the tissues about them, to 
make it successful. Not less than sixty-five to seventy- 
five per cent of all cancers in women occur in atrophy- 
ing organs, the uterus and mammary glands. 

A rather alluring suggestion was made by Cohnheim, 
years ago, that cancers might be due to the sudden 
resumption of growth on the part of islands or rests of 
embryonic tissue, left scattered about in various parts 
of the body. But these are now believed to play but a 
small part, if indeed any, in the production of true 


Finally, what can be done to prevent or cure this 
grotesque yet deadly process ? So far as it is conditioned 
by age, it is, of course, obvious that little can be done, 
for not even the most radical vivisector would propose 
preventing in any way as large a proportion as possible 
of the human race from reaching fifty or sixty, or 
even seventy years, to avoid the barely six per cent 
liability to cancer after forty-five. 

As regards the influence of chronic inflammations 
and irritation, much can be done, and here is our most 
hopeful field for prevention. Warts and birthmarks 
that are in any way^ subject to pressure or friction 
from clothing or movements should be promptly re- 
moved, as both show a distinctly greater tendency than 
normal tissue to develop into cancer. Cracks, fissures, 
chafes, and ulcers of all sorts, especially about the lips, 
tongue, mammary gland, uterus, and rectum, should 
be early and aseptically dealt with. Jagged remnants 
of teeth should be removed, all suppurative processes 
of the gums antiseptically treated, and the whole mouth- 
parts kept in a thoroughly aseptic condition. 

Thorough and conscientious attention to this sort 
of surgical toilet work is valuable, not only for its 
preventive effect, which is considerable, but also 
because it will insure the bringing under competent 
observation at the earliest possible moment the be- 
ginnings of true cancer. 

For the disease itself, after it has once started, there 
is, like treason in the body-politic, but one remedy 
capital punishment. Parleying with the rebels is worse 
than useless. Pastes, caustics, X-rays, trypsin, ra- 


dium, all are fatally defective, because they suppress 
a symptom only and leave the cause untouched. Only 
in one form of surface-cancer, the so-called flat-celled 
or rodent ulcer, which has little or no tendency to form 
spore-cells and attack the deeper organs, are they 

Nothing is easier and nothing more idle than to de- 
stroy and break down cells which have actually become 
cancerous; but so long as there remains in the body a 
single nest, or even cell, of the organ in which the re- 
volt started, so long the life of the patient is in danger. 

Absolutely the only remedy which is of the slightest 
value is complete removal with the knife. The one su- 
periority of the knife, shudder as we may at the name 
of it, over every other means of removal lies solely in 
this fact, that with it can be removed not merely the 
actual cancer, but the entire gland or group of sur- 
rounding cells in which this malignant, parricidal 
change has begun to occur. 

The modern radical operations for cancer take not 
merely the tumor, but the entire diseased breast, for 
instance, and all the lymph-glands into which it drains, 
clear up into the armpit, with the muscles beneath it 
down to the ribs. Where this is done early enough, the 
disease does not recur. Such radical and complete am- 
putation of an organ or region as this is possible in 
from two-thirds to three-fourths of all cases if seen 
reasonably early. 

With watchfulness and courage, our attitude toward 
the cancer problem is one of hopeful confidence. 



REATNESS always has its penalties. Other ills 
besides death love a shining mark. Pain is one 
of them, and headache its best exemplar. If there be 
one thing about our bodies of which we are peculiarly 
and inordinately proud it is that expanded brain-bulb 
which we call the head. Yet it aches oftener than all the 
rest of us put together. Headache is the commonest of 
all pains, which fact gives the slight consolation that 
everybody can sympathize with you when you have it. 
One touch of headache makes the whole world kin, and 
the man or woman who has never had it would be 
looked upon as a creature abnormal and "a thing 
apart." It has even become incorporated into our 
social fabric as one of the sacred institutions of the 
game of polite society. How could we possibly protect 
ourselves against our instructors in youth and our 
would-be friends in later life if there were no such 
words as " a severe headache" ? 

What is a headache, and why does it ache the head ? 
This is a wide and hotly disputed problem. But one 
fact, which is obvious at the first intelligent glance, 
becomes clearer and more important with deeper study, 
and that is that it is not tJw fault of the head. When 
the head aches, it is, nine times out of ten, simply doing 
a combination of scapegoat and fire-alarm duty for the 


rest of the body. Just as the brain is the servant of the 
body, rather than its master, so the devoted head 
meekly offers itself as a sort of vicarious atonement 
for the sins of the entire body. It is the eloquent spokes- 
man of such " mute, inglorious Miltons " as the stomach, 
the liver, the muscles, and the heart. The humblest 
and least distinguished of all the organs of the body 
can order the lordly head to ache for it, and the head 
has no alternative but to obey. 

To discuss the cause of headaches is like discussing 
the cause of the human species. It is one of the com- 
monest facts of every-day observation, and can be 
demonstrated almost at will, that any one of a hundred 
different causes, a stuffy room, a broken night's sleep, 
a troublesome letter, a few extra hours of work, eating 
something that disagrees, a cold, a glare of light in the 
eyes, any and all of these may bring on a headache. 
The problem of avoiding headaches is the problem of 
the whole conduct of life. 

Two or three broad generalizations, however, can 
be made from the confused and enormous mass of 
data at our disposal, which are of both philosophic 
interest and practical value. One of these is that, 
while headache is felt in the head, and particularly 
in those regions that lie over the brain, the brain has 
comparatively little to do with the pain. Headache is 
neither a mark of intellectuality, nor, with rare excep- 
tions, a sign of cerebral disturbance. Indeed, it is far 
more a matter of the digestion, the muscles, and the 
ductless glands, than it is of the brain, or even of the 
nervous system. It is, therefore, idle to endeavor 


either to treat or try to prevent it by measures directed 
to the head, the brain, or even the nervous system as 

Secondly, it is coming to be more and more clearly 
recognized that, while its causes are legion, a very large 
percentage of these practically and eventually operate 
by producing a toxic, or poisoned, condition of the blood, 
which, circulating through certain delicate and sensi- 
tive nerve-strands in the head and face, give rise to the 
sensation of pain. 

Thirdly, the tissues which give out this pain-cry 
under the torture of the toxins in the blood are, in 
a large majority of cases, neither the brain, nor the 
nerves of the eye, nor other special senses, but the 
nerves of common sensation which supply the face, 
the scalp, and the structures of the head generally, 
most of them derived from one great pair of nerve- 
trunks, the so-called Trigeminus, or fifth pair of 
cranial nerves. Strange as it may seem, the brain sub- 
stance is comparatively insensitive to pain, and the 
acutest pain of an operation upon it, such as for the 
removal of a tumor, is over when the skin and scalp 
have been cut through. These poisons, of course, 
go all over the body, wherever the circulation goes, 
but they produce their promptest and loudest pain 
outcry, so to speak, in the region where the nerves are 
most exquisitely sensitive. When your head aches, 
nine times out of ten your whole body is suffering, 
but other regions of it are not able to express them- 
selves so promptly and so clearly. 

These newer and clearer views of the nature of 


headache dispose at once of some of the most time- 
honored controversies in regard to its nature. In my 
student-days one of the most hotly debated problems 
in medicine was as to whether headaches were due to 
lack of blood (anaemia) or excess of blood (hyper- 
semia) in the brain. Few things could have been more 
natural for both the sufferer in, and the observer of, a 
case of throbbing, bursting headache, where every 
pulse-beat is registered as a thrill of agony, than to 
draw the conclusion that the pain was due to a huge 
engorgement and swelling of the brain with blood, 
resulting in agonizing pressure against its rigid, bony 

One of the most naive and vivid illustrations of this 
conception of headache is the remedy adopted for 
generations past, in this all too familiar and distressing 
condition, by the Irish peasantry. It consists of a band 
or strip of tough cloth, or better, of twisted or plaited 
straw, which is tied around the head and then tightened 
vigorously by means of a stick inserted tourniquet 
fashion. This is believed to prevent the head, which is 
aching "fit to split," from actually bursting open, and 
is considered a cure of wondrous merit through many 
a countryside. Ludicrous as is the reason which is 
gravely assigned for its use, it does, in some cases, 
greatly relieve the pain, a fact which we were entirely 
at a loss to account for until our later knowledge showed 
us that the pain, instead of being inside the skull, was 
outside of it in the sensitive nerves supplying the scalp. 
By steady pressure of this sort upon the trunks of these 
nerves, pressing them against the bone, they can be 


gradually numbed into a condition of anaesthesia, 
when naturally the pain would diminish. 

In politer circles a similar misapprehension has also 
given rise to a favorite form of treatment. That is the 
application of cold in the form of the classic wet cloth 
sprinkled with eau de Cologne. The mere mention of 
headache calls up in the minds of most of us memories 
of a darkened room, a pale face on the pillow with a 
ghastly bandage over the eyes, and a pervading smell 
of eau de Cologne. It was a perfectly natural conclusion 
that, because the head throbbed and felt hot and burst- 
ing, there must be some inflammation, or at least con- 
gestion, present, and that the application of cold would 
relieve this. The results seemed to justify this belief, 
for in many cases the sense of coolness to the aching 
head gives great relief ; but this is apt to be only tem- 
porary, and in really severe cases makes the situation 
worse by adding another depressing influence cold 
to the toxin-burdens that are weighing upon the 
tortured nerves. The chief virtue in these cold cloths 
and handkerchiefs soaked in cologne was that you 
were compelled to lie down and keep perfectly still in 
order to keep them on, while at the same time they 
mechanically blindfolded you. Few better devices for 
automatically insuring that absolute rest, which is the 
best and only rational cure for a headache, have ever 
been invented. 

We were not long in discovering that headaches, 
both of the mildest and the severest types, might be ac- 
companied either by a rush of blood to the head, 
with flushing of the skin, reddening of the eyes, and a 


bursting sense of oppression in the head, or, on the other 
hand, by an absolute draining of the whole floating 
surplus of the blood into the so-called " abdominal 
pool," the huge network of vessels supplying the di- 
gestive organs, which, when distended, will contain 
nearly two-thirds of the entire blood of the body, 
leaving the face blanched, the eyes white and staring, 
and the brain so nearly emptied of blood as to cause 
loss of consciousness or swooning. Other headaches, 
again, will be accompanied by a fresh, natural color 
and a perfectly normal and healthy distribution of 
the blood-supply. In short, the amount of blood in 
the head, whether plus or minus, has practically 
nothing to do with the pain, but depends solely upon 
the effect of the poisons producing it upon the heart 
and great blood-vessels. 

A good illustration of the full-blooded type of head- 
ache is that which so very frequently, indeed almost 
invariably, occurs in the early stage of a fever or other 
acute infection, such as typhoid, pneumonia, or blood- 
poisoning, Here the face is red, the eyes are bloodshot 
and abnormally bright, the pulse is rapid and full, the 
headache so severe as to become the first disabling 
symptom in the disease, all because this is the effect 
of the poison (toxin) of the disease upon the heart, the 
temperature, and the surface blood-vessels. Fortu- 
nately for the sufferer, this head -pain, like most others 
in the course of severe infections, is only preliminary, 
for as soon as the tissues of the body have become 
thoroughly saturated with the toxins, the nerves be- 
come dulled and semi-narcotized, so that they no 


longer respond with the pain-cry. As the patient settles 
down into the depression and dullness of the regular 
course of the fever, the headache usually subsides into 
little more than a sense of heaviness, or oppression and 
vague discomfort. 

Moral : It is a sign of health to be able to feel a head- 
ache, an indication that your body is still fighting 
vigorously against the enemy, whether traitor within 
or foe without. 

On the other hand, many of our most agonizing, 
and particularly our most persistent and obstinate 
headaches, occur in individuals who are markedly 
anaemic, with a low, weak pulse, poor circulation, 
blanched lips, and dull, lackluster eyes. The one and 
only thing in common between these two classes of 
" head-achers " is that their blood and tissues are loaded 
with poisons. Whether produced by invading germs 
or by starvation and malnutrition of the body-tissues 
makes no difference to the headache nerves. Their 
business, like good watchdogs, is to bark every time 
they smell danger of any sort, whether it be bears or 
book-agents. One of the most valuable services ren- 
dered us by our priceless heads is aching. 

This view of the nature of headache explains at once 
why it is so extraordinarily frequent and so extraordi- 
narily varied in causation. It is not too much to say 
that any influence that injuriously affects the body 
may cause a headache. It would, of course, be idle 
even to attempt to enumerate the different causes and 
kinds of this pain, as it would involve a review of the 
entire environment of the human species, internal and 


external. It makes not the slightest difference how the 
poison gets into the blood, or where it starts. A piece 
of tainted meat or a salad made from spoiled tomatoes 
will produce a headache just as promptly and effec- 
tively as an over-exposure to the July sun or an attack 
of influenza. It is even practically impossible to pick 
out from such a wealth of origins two or three, or even 
a score of, conditions which are the most frequent, 
most important, or the most interesting causes. The 
most exasperating thing about dealing with a head- 
ache is that we never know, until its history has been 
most carefully examined, whether we have to do with 
a mere temporary expression of discomfort and un- 
balance, due to overfatigue, errors in diet, a stuffy room, 
lack of exercise, or what-not, which can be promptly 
relieved by removing the cause ; or whether we have to 
deal with the first symptoms of a dangerous fever, the 
beginning of a nervous breakdown, or an early warn- 
ing of some grave trouble in kidneys, liver, or heart. 

The one thing, however, that stands out clearly is 
that headache always means something ; that it should 
be promptly and thoroughly investigated with a view 
to finding and removing the cause, never as some- 
thing which is to be cured as quickly as possible, as the 
police cure social discontent, by clubbing it over the 
head, with some narcotic or other symptom-smotherer. 
Nor should it be regarded as a malady so trifling that 
it is best treated with contempt, and still less as a mere 
"thorn in the flesh," whose ignoring is to be counted 
a virtue, or whose patient endurance without sign a 
mark of saintship. Martyrdom is magnificent when it 


is necessary, but many forms of it are sheer stupidity. 
Don't either gulp down some capsule, or "grin and 
bear it." Look for the cause. The more trivial it is, 
the easier it will be to discover and remove before seri- 
ous harm has been done. The less easy you find it to 
put your finger upon it, the more likely it is to be serious 
or chronic, and the more necessary it is to remove it. 

Once, however, we have clearly recognized that no 
headache should be treated too lightly or indifferently, 
it may be frankly admitted that practically the vast 
majority of headaches in which we are keenly interested 
that is, the kind that we individually or the members 
of our family habitually indulge in do form a mod- 
erately uniform class among the hundreds of varieties, 
and are in the main due to some six or seven great 
groups of causes. We have learned by repeated and 
unpleasant experience that they are very apt to " come 
on" in about a certain way, after a certain set of cir- 
cumstances; that they last about so long, that they 
are made worse by such and such things, that they are 
helped by other things, and that they generally get 
better after a good night's sleep. 

One of the commonest causes of this group of re- 
current and self-limited headaches is fatigue, whether 
bodily, mental, or emotional. This was long an appar- 
ent stumbling-block in the way of a poison theory of 
headache, but now it is one of its best illustrations. 
Physiologists years ago discovered that what produced 
not merely the sensation but also the fact of fatigue, or 
tiredness, was the accumulation in the muscles or 
nerves of the waste-products of their own activities. 


Simply washing these out with a salt solution would 
start the utterly fatigued muscle contracting again, 
without any fresh nourishment or even period for rest. 
It has become an axiom with physiologists that fatigue 
is simply a form of self -poisoning, or, as they sonorously 
phrase it, autointoxication. One of the reasons why 
we are so easily fatigued when we are already ill, or, 
as we say, " out of sorts," is that our tissues are already 
so saturated with waste-products or other poisons 
that the slightest addition of the fatigue poisons is 
enough to overwhelm them. This also explains why 
our pet variety of headache, which we may have clearly 
recognized to be due to overwork or overstrain of 
some sort, whether with eye, brain, or muscles, is so 
much more easily brought on by such comparatively 
small amounts of overexertion whenever we are already 
below par and out of sorts. People who are "born 
tired," who are neurasthenic and easily fatigued and 
" ached," are probably in a chronic state of self -poison- 
ing due to some defect in their body-chemistry. Fur- 
ther, the somewhat greater frequency and acuteness of 
headache in brain workers although the difference 
between them and muscle workers in this regard has 
been exaggerated is probably due in part to the 
greater sensitiveness of their nerves ; but more so to the 
curious fact, discovered in careful experiments upon 
the nervous system, that the fatigue products of the 
nerve-cells are the deadliest and most powerful poisons 
produced in the body. Hence some brain workers can 
work only a few half-hours a day, or even minutes at 
a time ; for instance, Darwin, Spencer, and Descartes. 


A very frequent cause of these habitual headaches, 
really a subdivision of the great fatigue group, is eye- 
strain. This is due to an abnormal or imperfect shape 
of the eye, which is usually present from birth. Hence, 
the only possible way of correcting it is by the addition 
to the imperfect eye of carefully fitted lenses or spec- 
tacles which will neutralize this mechanical defect. To 
put it very roughly, if the eye is too flat to bring the 
light-rays to a focus upon the retina, which is far the 
commonest condition (the well-known "long sight," 
or hyperopia), we put a plus or bulging glass before 
the eye and thus correct its shape. But if the eye is 
too round and bulging, producing the familiar " short 
sight," or myopia, we put a minus or concave lens 
before the eye, and thus bring it back to the normal. 
By a curious paradox, however, it often happens that 
the headache due to eyestrain is caused not by the 
grosser defects, such as interfere with vision so seri- 
ously as absolutely to demand the wearing of glasses 
to see decently, but from slighter and more irregular 
degrees and kinds of misshapenness in the eye, most 
of 'which fall under the well-known heading of astig- 
matism. These interfere only slightly with vision, but 
keep the eye perpetually on the strain, on a twist, as it 
were, rasping the entire nervous system into a state of 
chronic irritation. Our motto now, in all cases of 
chronic headache, is, first examine the patient's habits 
of life, next his eyes. 

Many forms of headache are really stomach-ache 
in disguise, due to digestive disturbances, the absorp- 
tion of poisons from the food-tube, whether from 


tainted, spoiled, or decayed foods, as in the now fa- 
miliar ptomaine poisoning, or from imperfect pro- 
cesses of digestion. The immediate effect, however, of 
diet in the causation of headache is not so great as 
we once believed. We have no adequate basis for be- 
lieving that any particular kinds or amounts of food 
are especially likely to produce either headache or 
what we might call the headache habit, except in so 
far as they upset the digestion. In a certain number 
of susceptible individuals, however, it will be found 
that some particular kind of food, often perfectly whole- 
some and harmless in itself, will bring on an attack of 
headache whenever it is indulged in. Very frequently 
the disturbances of digestion which are put down as the 
cause of a headache are only symptoms of some general 
constitutional lack of balance, as eyestrain or neuras- 
thenia, which is the cause of both these discomforts. 
Far fewer headaches can be cured by dieting than we 
at one time believed, and underfeeding is a more fre- 
quent cause than overeating. 

By an odd boukversement the one type of headache 
which we have almost unanimously in the past attri- 
buted to digestive disturbances, the famous, or, rather, 
infamous, "sick headache," is now known to have 
little or nothing to do with the stomach in its origin. In 
fact, incredible as it may seem at first sight, it is the 
headache that causes the sickness, not the sickness 
the headache. Stop the pain of a sick headache in the 
early stage, and the sickness will never develop at 
all. The vomiting of sick headache is an interesting 
illustration of vomiting due to disturbances of the brain 


and nervous system, technically known as central 
vomiting. Another illustration is the vomiting of sea- 
sickness, due solely to dizziness from the gross con- 
tradiction between the testimony of our eyes and of the 
balancing canals in the inner ear. The stomach or its 
contents has no more to do with seasickness than the 
water in a pump has with the plunger. Injuries to the 
head will bring on severe and uncontrollable vomiting, 
and the severer type of fevers is very frequently ushered 
in by this curious sign. As to what it means, we are 
as yet utterly in the dark, for in none of these condi- 
tions does the process do the slightest good, but simply 
adds to the discomfort of the situation. It would appear 
to be a curious echo of ancestral times, when the animal 
was pretty much all stomach, and hence emptying that 
organ would probably relieve two-thirds of his dis- 
comforts. Whatever the explanation, the fact re- 
mains that whenever our nervous system gets about 
so panic-stricken, it promptly begins throwing its cargo 
overboard, in the blind hope that this may somehow 
relieve the situation. The bile that we bring up at the 
end of these interesting acrobatic performances and 
which makes us feel so much better, because we 
have now got the cause of the trouble out of our system, 
is simply due to the prolonged vomiting, which has 
reversed the normal current and caused the perfectly 
healthy bile from our unoffending liver to pass upward 
into the stomach, instead of downward into the bowels. 
In another great group of headaches natural poisons 
or waste-products are not burned up or got rid of 
through the body-sewers and pores as rapidly as they 


should be; for instance, the familiar headache from 
sitting too long in a stuffy room. Your well-known 
and well-earned discomfort is, of course, due in part 
to the irritating and often poisonous gases, dust, and 
bacteria, which are present in the air of an unventi- 
lated room ; but it is also due to the steady piling up of 
the waste products of your own tissues. These poisons 
are normally oxidized in the muscles, burned up and 
exhaled through the lungs, and sweated out through 
the skin, all three of which relief agencies are, of 
course, practically paralyzed, or working at lowest 
possible level, while you are sitting at your desk. 

The well-known headache of sluggish bowels is an 
obvious case in point; and one of the early signs of 
beginning failure of the kidneys, as in Bright's disease, 
is a headache of a peculiar type due to accumulation in 
the system of the poisons which it is their duty to get 
rid of. 

There are few things the head resents more keenly 
than loss of sleep. The pillow is the best headache 
medicine. If this loss of sleep be due to the encroach- 
ments of work or of amusements, then the mechanism 
of its production is obvious. The fatigue poisons pro- 
duced during the day and normally completely neu- 
tralized and burned up during sleep are not entirely 
disposed of and remain in the tissues to torture the 
nerves. The headache of insomnia, or habitual sleep- 
lessness, on the other hand, is not, strictly speaking, 
caused by loss of sleep. Paradoxical as it may sound, 
the fatigue poisons, which in moderate amounts w T ill 
produce drowsiness and promote sleep, in excessive 


amounts will cause wakefulness and inability to sleep. 
Insomnia and headache are usually symptoms of this 
overfatigued, or poisoned, condition, and should both 
be regarded and treated as symptoms by the removal 
of their causes, not by the use of coal-tar products and 

Another common cause of headache is nasal ob- 
struction, such as may be due to adenoids or deformities 
of the septum, or chronic catarrhal conditions. These 
probably act by their interference with breathing and 
consequent imperfect ventilation of the blood, as well 
as by obstruction and, inflammation of the great air- 
spaces in the bones of the skull, closely underlying the 
brain, which open and drain into the nose. 

It may be remarked in passing that " sick headache," 
or migraine, though long and painfully familiar to us, 
is still a puzzle as to its cause. But the view which 
seems to come nearest to explaining its many eccen- 
tricities is that it is usually due to a congenital defect, 
not so much of the nervous system as of the entire 
body, by which the poisons normally produced in its 
processes fail to be neutralized and got rid of, and 
gradually accumulate until they saturate the system 
to such a degree as to produce a furious explosion of 
pain. This defect may quite possibly be in one of the 
ductless glands or in some of the internal secretions, 
rather than in the nervous system. 

Obviously, after what has been said of the wo rid-wide 
causation of headache, to attempt to discuss its treat- 
ment would be as absurd as to undertake to advise 
what should be done for the relief of hunger, for " that 


tired feeling," or for a pain in the knee. The treatment 
for a headache due to an inflammation or tumor of the 
brain would, of course, be wide as the poles from that 
which would relieve an ordinary fatigue or indigestion 
pain. Besides, it is utterly irrational and often harmful 
to attempt to treat any headache as such. That is the 
open road to the morphine habit and drug addictions 
of all sorts. Remedies and there are plenty of them 
which simply relieve the pain without doing any- 
thing to remove its cause, merely make the latter 
state of that individual worse than the first. Headache 
is always and everywhere nature's vivid warning that 
something is going wrong, like the shrieking of a wagon- 
axle or the clatter of a broken cog in machinery. 

There is, however, fortunately one remedy which 
alone will cure ninety-nine per cent of all headaches, 
and that is rest. The first thing an intelligent ma- 
chinist does when squeaking or rattling begins is to 
stop the machinery. This has the double advantage 
of preventing the damage from going any further and 
of enabling him to get at the cause. Headache, like 
pain anywhere, is nature's imperative order to Halt, 
at least long enough to find out what you are doing 
to yourself that you should n't. It makes little differ- 
ence what you take for your headache, so long as you 
follow it up by lying down for an hour or two, or, better 
still, by going to bed for the remainder of the day 
and sleeping through until the next morning. If more 
headaches were treated in this way there would not 
only be fewer headaches, but two-thirds of the risks 
of nervous breakdown, collapse, insomnia, and chronic 


degenerative changes in the liver, kidneys, and blood- 
vessels would be avoided. 

This, of course, is a counsel of perfection, and in- 
capable of general application for the sternest of rea- 
sons; but it does indicate the rational attitude toward 
headache and its treatment, and one which is coming 
to be more and more adopted. No motorist would 
dream of pushing ahead with a shrieking axle or a 
scorching hot box, unless his journey were one of most 
momentous importance or a matter of life and death. 
Pain is nature's automatic speed regulator. It is often 
necessary to disregard it, to get the work of the world 
done and to discharge our sacred obligations to others ; 
but this disregarding should not be exalted to too high 
a pinnacle of virtue, and least of all worshiped as in- 
herently and everywhere a mark of piety and one of the 
insignia of saintship. 

A business firm or a factory, for instance, which 
would send home for the day each of its employees 
who reported a genuine case of bad headache, would, 
in the long run, save money by avoiding accidents, 
mistakes, muddles, and confusions, often involving 
a whole department, due to the kind of work that is 
done by a man or woman who is physically unfit to 
attempt it. And the higher the type of work that has 
to be done, the more the elements of insight, grasp, and 
sound judgment enter into it, the graver and costlier 
are the mistakes that are likely to be made under such 

Of course, it will probably be objected at this point : 
" What is the use of wasting a day, or even half a day, 


when by taking two or three capsules of So-and-So's 
Headache Cure I can get rid of the pain and go right 
on with my work?" It is perfectly true that there are 
a number of remedies which will relieve the average 
headache; but there are two important things to be 
borne in mind. The first is that all of these are simply 
weaker or stronger nerve-deadeners ; most of them 
actual narcotics. All that they do is to stop the pain and 
thus cheat you into the impression that you are better. 
You are just as tired and as unfit for work as you were 
before. Your nervous system is just as saturated with 
poisons, and the chances are ten to one that the quality 
of the work that you do will be just as bad as if you had 
taken no medicine. Further, like alcohol, when used 
as a " pick-me-up " under somewhat similar conditions, 
the remedy which you have taken, while producing 
a false sense of comfort and even exhilaration by dead- 
ening your pain and discomfort, in that very process 
itself takes off the finer edge of your judgment, the 
best keenness of your insight, and the highest balance 
of your control. In short, your nervous system has to 
struggle with all the poisons that were present before, 
with another one added to them ! 

After you have taken nature's wise advice, and 
obeyed her orders, and put yourself at rest, then there 
are a number of mild sedatives, with which every 
physician is familiar, one of which, according to the 
special circumstances of your case, it may be perfectly 
legitimate to take in moderate doses, with the approval 
of a physician, as a means of relieving the pain and 
helping to get that sleep which will complete the cure. 


One other measure of relief, which, like rest, is also 
indicated by instinct, is worth mentioning, and that is 
gentle friction of the head. One of the most instinctive 
tendencies of most of us when suffering from a severe 
headache is to put the hands to the head, either for the 
purpose of frantically clutching at it, rubbing as if our 
lives depended upon it, or pressing hard over the aching 
region. The mere picture of a man with his head in his 
hands instantly suggests the idea of headache. Part 
of this is, of course, little more than a blind impulse to 
do something to or with the offending member. We 
would sometimes like^to throw it away if we could, or 
at others to bang it against the wall. But part of it is 
due to the discovery, ages ago, that pressure and fric- 
tion would give a certain amount of relief. 

For some curious reason the nerves most frequently 
involved are those which are most readily accessible 
for this kind of treatment, namely, the long nerve- 
threads which run from the inner third of the eyebrow 
up the forehead and over the crown of the head (the 
so-called supraorbital or frontal branches). A corre- 
sponding pair run up the back of the neck, about half- 
way between the back of the ear and the spinal column, 
supplying the back of the head and the crown (these 
form the cervical plexus) ; and a smaller pair run up 
just in front of the ear into the temple, and from there 
on upward to join the other two pairs at the top of the 

Broadly speaking, the position of the pain depends 
upon which pair of these nerves is lifting up its voice 
most vigorously in protest. If it be the front pair 


(supraorbitals) then we get the well-known frontal 
or forehead headache ; if the back pair (known as the 
occipitals) then we have the deadly, constricting, band- 
around-the-head pain which clutches us across the 
back of the neck and base of the brain. If the lateral 
pair are chiefly affected then we get the classic throb- 
bing temples. Practically all of these aches, however, 
are of the "fire-alarm" character; and while certain 
of these nerve-gongs show some tendency to respond 
more readily to calls coming in from certain regions 
of the body, as, for instance, the forehead nerves to eye- 
strain, the back-of-the-head nerves (occipital) to grave 
toxic states of the system, the tips of any of the nerves 
in the crown of the head to pelvic disturbances and 
anaemic conditions, the lateral branches in the temples 
to diseases of the teeth and throat, yet there is little 
fixed uniformity in these relations. Eyestrain, for 
instance, may cause either frontal or occipital head- 
ache; and, as every one knows from experience, the 
pain may be felt in all parts of the head at once. 

Gentle and intelligent massage over the course of 
these nerves of the scalp, according to the location of the 
pain, will often do much to relieve the severity of the 

Treat headache as a danger signal, by rest and the 
removal of its cause, and it will prevent at least ten 
times as much suffering and disability as it causes. 



NERVES are real things. In spite of their con- 
nection with imaginary diseases and mental dis- 
turbances, there is nothing imaginary or unsubstantial 
about them. There is no more genuine and obstinate 
malady on earth than a nervous disease. Because 
nerves lie in that twilight borderland between mind 
and matter, body and soul, the real and the ideal, the 
impression has got abroad that they are little better 
than figures of speech. Though their disturbances give 
rise to visions of all sorts there is nothing visionary 
about them; they are just as genuine and substantial 
a part of our bodily structure as our bones, muscles, 
and blood-vessels. In fact, it was this very substan- 
tiality that at the beginning prevented their proper 
recognition, and handicapped them with their present 
absurd and inappropriate name. 

" Nerve" is from the Greek neuron, meaning tendon, 
or sinew, and was originally applied indiscriminately 
to all the different shining cords which run down the 
limbs and among the muscles. In fact the first recog- 
nition of nerves was an utter failure to recognize. The 
tendon cords, which are the ropes with which the 
muscles work the joint pulleys, were actually included 
under one head with the less numerous but almost 
equally large and tough cords of grayer color, flatter 


outline, and less glistening hue, which were afterwards 
found to be nerve-trunks. Cutting either paralyzed 
the limb below the cut, and what more proof could 
you ask of their having the same function ? 

Such is the persistence of ancient memories, that 
any physician could tell you of scores of cases in which 
he has heard the naive remark, in reference most fre- 
quently to a deep gash across the wrist, that the 
"nerves" were cut, and the hand was paralyzed, when 
what had happened was simply that the tendons had 
been cut across. When, after centuries of blundering 
in every possible direction until the right one was 
finally stumbled upon (which is the mechanism of pro- 
gress), it was realized that some of these " nerves," the 
grayer and flatter ones, carried messages instead of 
pulling ropes, they were still far from being properly 

It is an amusing illustration of the blissful ignorance 
and charming naivete which marked their study and 
discussion at this time, that nerves were for centuries 
regarded as hollow tubes, carrying a supply of " animal 
spirits" from the central reservoir of the brain to the 
different limbs. So seriously was this believed, that, 
in amputations, the cut nerve-trunks were carefully 
sought out and tied, for fear the vital spirits would leak 
out and the patient thus literally bleed to death. One 
can imagine how this must have added to the comfort 
of the luckless patient. 

The term "nerves" still persists, in the old sense, 
in both botany and entomology, which speak of the 
"nerves" of a butterfly's wing, or the "nervation" of 


a leaf, meaning simply the branching, fibrous frame- 
work of each. 

It comes in the nature of a surprise to most of us to 
learn that "nerves" are real things. I shall never for- 
get the shock of my own first convincing demonstration 
of this fact. It was in one of the first surgical clinics 
that I attended as a medical student. A woman patient 
was brought in, with a history of suffering the tortures 
of the damned for a year past, from an uncontrollable 

It was a recognized procedure in those days (and is 
resorted to still) , when all medical, electrical, and other 
remedial measures had failed to relieve a furious 
neuralgia, for the surgeon to cut down upon the nerve- 
trunk, free it from its surrounding attachments, and, 
slipping his tenaculum or finger under it, stretch the 
nerve with a considerable degree of force. Whether 
it acts by merely setting up some trophic change in 
the nerve-tissue, or by tearing loose inflammatory 
adhesions which are binding down the nerve-trunk, 
the procedure gives excellent results, nearly always 
temporary relief, and sometimes a permanent cure. 

The patient was placed upon the table and anaes- 
thetized, and the surgeon made a free, sweeping in- 
cision down the back of the thigh, exposing the sciatic 
nerve. He thrust his finger into the wound, loosened 
up the adhesions about the nerve, hooked two fingers 
underneath it, and, to my wide-eyed astonishment, 
heaved upward upon it, until he brought into view 
through the gaping wound a flattened, bluish-gray 
cord about twice the size of a clothesline, with which 


he proceeded to lift the hips of the patient clear of the 
table. In my ignorant horror, I expected every moment 
to see the thing snap and the patient go down with a 
bump, paralyzed for life; but I never doubted after 
that that nerves were real things. Though it has 
nothing to do with this discussion, for the benefit of 
those of my readers who cannot bear to have a story 
left unfinished, I will add that the operation was as 
successful as it was dramatic, and the patient left the 
hospital completely relieved of her sciatica. 

When at last it was clearly recognized that the nerves 
were concerned in the sending of messages from the 
centre to the brain, known as sensory, or centripetal, 
and carrying back messages from the brain to the mus- 
cles and surface, known as motor, or centrifugal, in 
other words that they were the organs of the mind, 
still another source of confusion sprang up, and that 
was the determination on the part of some to regard 
them from a purely mental and, so to speak, spiritual 
point of view, and on the part of others to regard 
them from a physical and anatomical point of view. 
This confusion is of course in full riot at the present 

The term "nerves," and its adjective, "nervous," 
are used in two totally distinct senses : one, that which 
is vague and unsubstantial, purely mental or sub- 
jective, and, in the realm of disease at least, imaginary; 
the other, purely anatomical, referring to certain 
strands of tissue devoted to the purpose of transmitting 
impulses, and the condition affecting these strands. 
I am not so rash as to raise the question here, still 


less to attempt to settle it, which of these two views 
is the right and rational one. Whether the brain secretes 
thought as the liver does bile, or whether the mind 
created the brain and nervous system, or, as it has been 
epigrammatically put in a recent work on psychology, 
" whether the mind has a body, or the body has a mind," 
I merely call attention to the fact that this confusion 
of meanings exists, and that its injection into the field 
of medicine and pathology, at least, has done an enor- 
mous amount of harm in the way of confusing problems 
and preventing a proper recognition of the actual facts. 

The more carefully and exhaustively and dispas- 
sionately we study the disorders of the nervous system 
which come in the field of medicine, the more irre- 
sistibly we are drawn to the conclusion that from 
neurasthenia and hysteria to insanity and paralysis 
they are every one of them the result of some definite 
morbid change in some cell or strand of the nervous 
system. The man or woman who is nervous has 
poisoned nerve-cells, either from hereditary defect, 
or direct saturation of the tissues with toxic substances. 
The patient who has an imaginary disease is suffering 
from some kind of a hallucination produced by poison- 
soaked nerve-cells, such as in highest degree give 
rise to the delirium of fevers, and the horrid spectres 
of delirium tremens. 

Even the man who is suffering from a "mind dis- 
eased," and confined in one of our merciful asylums 
for the insane, is in that condition and position on 
account of physical disease, not merely of his brain, 
but of his entire body. The lunatic is insane, in the for 


once correct derivative sense of unhealthy, to the very 
tips of his fingers. Not merely his mind and his brain, 
but his liver, his stomach, his skin, his hair and finger- 
nails, the very sweat-glands of his surface which con- 
trol his bodily odor, are diseased arid have been so 
usually for years before his mind breaks down. 

Tell a competent expert to pick out of a crowd of 
a thousand men and women the ten who are likely to 
become insane, and his selection will be found almost 
invariably to include the two or three who will actually 
become so. 

In fact, from even the crudest and scantiest know- 
ledge of the actual growth of our own bodies from the 
ovum to the adult, it will be difficult to conceive how 
this relation could be otherwise, The nerve-cells and 
their long processes, which form the nerve-trunks, are 
simply one of a score of different specialized cells 
which exist side by side in the body. Primarily all 
our body-cells had the power of responding to stimuli, 
of digesting and elaborating food, of moving by con- 
traction, of reproducing their kind. The nerve-cells 
are simply a group which have specialized exclusively 
upon the power of receiving and transmitting impulses. 
They still take food, but it has to be prepared for them 
by the other cells ; and here, as we shall see later, is one 
of the dangers to which they are exposed. They still 
reproduce their kind, but in very much smaller and 
more limited degree. They still, incredible as it may 
seem, probably have slight powers of movement or 
contraction, and can draw in their processes. But they 
have surrendered many of their rights and neglected 


some of their primitive accomplishments, in order to 
devote themselves more exclusively and perfectly to 
the carrying out of one or two things. 

In spite of all this, however, they still remain blood- 
brothers and comrades to every other cell in the body. 
In the language of Shylock, " If you cut them, they 
will bleed ; if you tickle them, they will laugh ; if you 
starve them, they will die." In all this development, 
which continued up to a late hour last night, and is 
still going on, the nerve-tissue has lain side by side 
with every other tissue in the body, fed by the same 
blood, supplied with the same oxygen, saturated with 
the same body- lymph' 

It is of course perfectly clear that any influence, 
whether beneficial or injurious, affecting the body, 
will also be likely to affect the nervous system, as a part 
of it; and this is precisely the fact, as we find it. If 
the body be well fed, well warmed, sufficiently exer- 
cised, without being overworked, and allowed a liberal 
allowance of that recharging of the human battery 
which we call sleep, then the nervous system will 
work smoothly and easily, at peace with itself and with 
all mankind. Its sense-organs will receive external 
impressions promptly and accurately. Its conducting 
fibres will transmit them to the centre with neither de- 
lay nor friction. The brain clearing-house will receive 
and dispose of them with ease and good judgment. 
And then, just because his nervous system is working 
to perfection, we say that such an individual " has no 

If the triumph of art be to conceal art, then the 


nerves have achieved this. They have literally effaced 
themselves in the well-being of the body. 

If on the other hand, the food-supply is inadequate, 
if the sleep allowance has been cut short, whether by 
the demands of work or by those of fashion, if the body 
has been starved of oxygen and deprived of sunlight, 
if the whole system has been kept on the rack, whether 
in the sweatshop, or in the furnace of affliction, what 
is the effect on the nervous system ? Just what might 
have been expected. The sense-organs shy, like a fright- 
ened horse, at every shadow or fluttering leaf. The 
conducting wires break, and cross, and tangle in every 
imaginable fashion. The central exchange, half wild 
with hunger, or crazed with fatigue-toxins, shrieks 
out as each distorted message comes in, or sulks be- 
cause it can't understand them. And then, with charm- 
ing logicality, we declare that such an one is "all 

The brain, by which we mean the biggest one near 
the mouth, we have little brains, or ganglia all over 
our bodies, so far from being an absolute monarch, 
is not even a constitutional one, or a president of a 
republic, but a mere house of congress of the modern 
type, which can do little but register and obey the 
demands of its constituents. The brain originates 
nothing. Impulses are brought to it from the sense- 
organs by the nerves. They set up in it certain vibra- 
tions, or chemical disturbances. It responds to these 
much as blue litmus paper turns red when a weak acid 
is dropped on it, or as lemonade fizzes when you put 
soda in it. If more than one of these vibrations are 


set up simultaneously, it " chooses " between them, 
by responding to the strongest. If the response differs 
from the stimulus, it is because of its huge deference 
to precedent as established by the records of previous 
stimuli with which its tissues are stored. 

This brings us to the interesting and important ques- 
tion, What are the causes of these disturbances of the 
nerve-tissues ? Probably the most important single re- 
sult that has been reached in our study of nervous dis- 
eases in the last fifteen years, is that the cause of them 
in easily eighty per cent of all cases lies entirely out- 
side of the nervous system. 

The stomach burns, the nerve-tissues send in the 
fire alarm and order out the engines. The liver goes 
on a strike, and the body-garbage, which it has failed 
to burn to clean ashes and clear smoke, poisons the 
nerve-cells, and they remonstrate accordingly, on be- 
half of the other tissues. The heart, or blood-vessels, 
fails to supply a certain muscle with its due rations of 
blood and the nerves of the region cry out in the agony 
of cramp. 

We have discovered, by half a century of careful 
study in the hospital and in the sick-room, not only 
that the nerve-tissues are usually poisoned by defect 
of other tissues of the body, but that they are among the 
very last of the body-stuffs to succumb to an intoxica- 
tion. The complications of a given disease involving 
the nervous system are almost invariably the last of 
all to appear. This is one of the things that has given 
nervous diseases such a bad name for unmanageable- 
ness and incurableness, and that for years made us 


regard their study as so nearly hopeless, so far as any 
helpful results were concerned. 

When a disease has, so to speak, soaked into the in- 
most core of the nerve-fibre, it has got a hold which it 
will take months and even years to dislodge. And be- 
fore your remedies can reach it, it will often have done 
irreparable damage. An illustration of the care taken 
to spare the nervous system is furnished by its be- 
havior in starvation. If a man or an animal has almost 
died of starvation, the tissues of the body will be found 
to have been wasted in very varying degrees, the fat, 
of course, most of all ; in fact this will have almost en- 
tirely disappeared, all but three per cent. Then come 
the liver and great glands, which will have shrunk about 
sixty per cent ; then the muscles, thirty per cent ; then 
the heart and blood-vessels. Last of all, the nervous 
system, which will scarcely have wasted to any appre- 
ciable degree. In fact, it is an obvious instance of 
jettison on the part of the body, throwing overboard 
those tissues which it could most easily spare, and 
hanging on like grim death to those which were ab- 
solutely essential to its continued existence, viz., the 
heart and the nervous system. To use a cannibalistic 
and more correct illustration, it is killing and eating 
the less useful and valuable members of its family, in 
order that their flesh may keep alive the two or three 
most indispensable. 

Another illustration is the actual behavior of the 
nerve-stuff in disease. This is most clearly shown 
in those clear-cut disturbances which are definitely 
known to be due to a specific infection; in other 


words, invasion of the body by a disease-organism, or 

First of all, it may be stated that physicians are now 
substantially agreed that two-thirds of the general 
diseases of the nervous system are due to the extension 
of one of these acute infections to the nerve-tissue ; and 
this extension almost invariably comes late in the dis- 
ease. The only exceptions to this rule in the whole list 
of infectious diseases are two, epidemic cerebro-spinal 
meningitis (spotted fever), and tetanus (lockjaw). 
Both of these have an extraordinary and deadly pre- 
ference for the nervous system from the very start, and 
this is what gives them their frightful mortality and 
discouraging outlook. Even of this small number of 
exceptions, we are not altogether certain as to epi- 
demic meningitis, inasmuch as we do not know how 
long the germ may have existed in the other tissues 
of the body before it succeeded in working its way to 
and attacking the brain and spinal cord. 

The case of tetanus, however, is perfectly clear in 
this regard, and exceedingly interesting, inasmuch 
as it explains why a disease specially involving the ner- 
vous system from the start is so excessively hard to 
check or cure. The germ of the disease, long ago iden- 
tified as one having its habitat in farm or garden soils, 
particularly those which have been heavily fertilized 
with horse manure, gets into the system through 
a cut or scratch upon the surface, into which the soil 
is rubbed. These infected cuts, for obvious reasons, 
are most frequently upon the hands or feet. 

Small doses of the organism have been injected into 


animals ; then, when they have recovered, larger ones, 
and so on, after the manner of the bacillus of diphtheria, 
until a powerful antitoxin can be obtained from their 
blood, very minute quantities of which will promptly 
kill the bacilli in a test-tube. For seven or eight years 
past we have been injecting this into every patient 
with tetanus that came under our observation, but so 
far with very limited benefit, even though the injections 
were made directly into the spinal cord, or brain 
substance. The problem puzzled us for years, until 
finally Cattani stumbled upon the explanation. While 
we had been supposing that the poison was carried, 
as almost every other known poison is, through the 
blood-vessels, or lymph-channels, to the heart and 
thence to the brain, he clearly proved that it ran up the 
central axis of the nerve- trunks, and consequently, 
when it had got once fairly started up this channel, 
was as safe from the attack of any antitoxin merely 
present in the general circulation and fluids of the 
body, as the copper of the Atlantic cable is from the 
eroding action of the sea-water. If, in his experimental 
animals, he carefully sought for the cut end of the 
nerve- trunk in the wound that had been infected, and 
injected the antitoxin directly into that, the disease 
was stopped. Or it might even be "headed off" by 
the crude method of cutting directly across the nerve- 
trunk at a point above that yet reached by the infec- 

The cotmnonest and most fatal of all forms of general 
diseases of the nervous system are those which are 
due to the later extensions of general infections. 


First and foremost stands syphilis, due to the in- 
vasion of the blood by a clearly defined spirillum, the 
Treponema pallida of Schaudinn. This first attacks 
the mucous membranes of the throat and mouth, then 
the skin, then the great internal organs like the liver 
and stomach, then the bones, and, last of all, the ner- 
vous system. The length of time which the poison 
takes to reach the nervous system is something which 
at first sight is almost incredible, viz., from one and a 
half to fifteen years. It is true that in rare instances 
brain symptoms will manifest themselves within six 
or eight months ; but these are usually due to pressure 
by inflammatory growths on the bones of the skull and 
its lining membrane (dura mater) . It is not too much 
to say that this disease plays the greatest single role in 
nervous pathology. Three of the commonest and most 
fatal diseases of the spinal cord and brain, paresis 
(general paralysis of the insane) , locomotor ataxia, and 
lateral sclerosis, are due to it. 

Naturally, when a poison has taken a decade or a 
decade and a half to penetrate to the nerve-tissues, it 
does irreparable damage long before it can be dis- 
lodged or neutralized. 

A similar aftermath may occur in almost all of the 
acute infectious diseases. Every year adds a new 
one to the list capable of causing cerebral complica- 
tions. Tuberculosis, diphtheria, scarlet fever, typhoid, 
smallpox, influenza, have now well-recognized cerebral 
and nervous complications, some temporary, some 
permanent. A form of tuberculosis attacking the cover- 
ings (meninges) of the brain hence known as men- 


ingitis is far the commonest fatal brain-disease of 
infancy and childhood. 

Perhaps the most striking illustration of just how 
acute affections attack the nervous system, is that 
furnished by diphtheria. A child develops an attack 
of this disease, passes the crisis safely, and begins to 
recover. A few days later, it is allowed to sit up in bed. 
Suddenly, after some slight exertion, or often without 
any apparent cause, the face blanches, the eyes stare 
widely, the child gasps two or three times, and is dead : 
sudden heart failure, due to the poisoning either of 
the heart muscle itself, or of the nerves supplying the 
heart, by the toxin of the disease. Moral : Keep diph- 
theria patients strictly at rest in bed for at least a week 
after the crisis is past. Another case will pass this 
period safely, though perhaps with a rapid and weak 
heart, for days or weeks; then one morning the child 
will choke when swallowing milk. The next time it is 
attempted, the milk, instead of going down the throat, 
comes back through the nostrils. Paralysis of the soft 
palate has developed, apparently from a local satura- 
tion of the nerves with the poison. This may go no 
further, or it may extend, as it commonly does, to the 
nerves of the eye, and the child squints and can no 
longer read, if old enough, because the muscle of ac- 
commodation also is paralyzed. The arms and limbs 
may be affected, and in extreme cases the nerves of res- 
piration supplying the diaphragm may be involved, 
and the child dies of suffocation. In the majority of 
cases, however, fortunately, after this paralysis has 
lasted from three to six weeks, it gradually subsides, 


and may clear up completely, though not at all infre- 
quently one or more muscles may remain permanently 
damaged by the attack, giving, for instance, a palatal 
tone to the voice, or interfering with the production of 
singing tones. Occasionally a permanent squint may 

It might be said in passing, that, with one of the 
charming logicalities of popular reasoning, these nerve 
complications have been said to be caused by antitoxin, 
simply because the use of the antitoxin saves more 
children alive to develop them. 

The next group of nervous diseases may be roughly 
described as due to the failure of some part of the di- 
gestive system, like the stomach and intestines, properly 
to elaborate its food ; or of one of the great glands, like 
the liver, thyroid, or suprarenal, properly to supply 
its secretion, which is needed to neutralize the poisons 
normally produced in the body. This class is very 
large and very important. It has long been known how 
surely a disordered liver "predicts damnation"; 
melancholia; or "black bilious condition," hypochon- 
dria, or " under the rib-cartilages " (where the liver 
lies) , are every-day figures of speech. A thorough house- 
cleaning of the alimentary canal, together with proper 
stimulation of the skin and kidneys, and an intelligent 
regulation of diet, are our most important measures 
in the treatment of diseases of the nervous system, even 
in those extreme forms known as insanity. 

Closely allied to these are those disturbances of the 
nervous system lumped together under the soul-satis- 
fying designation of "neurasthenia," which are chiefly 


due to the accumulation in the system of the fatigue 
poisons, or substances due to prolonged overstrain, 
under-rest, or underfeeding of the system. Neuras- 
thenia is the "fatigue neurosis," as a leading expert 
terms it. It may be due to any morbid condition under 
heaven. It is "that blessed word Mesopotamia" of the 
slipshod diagnostician. Nearly one-fourth of the cases 
which come into our sanatoria for tuberculosis have 
been diagnosed and treated for months and even years 
as "neurasthenia." It satisfies the patient and it 
means nothing; though some experts contend for a 
distinct disease entity of this name but admit its 

The intelligent neurologist, nowadays, has practi- 
cally no known specific for any form of nervous disease, 
no remedy which acts directly and curatively upon the 
nervous system itself. He relies chiefly and this 
applies to the asylum physician also upon intestinal 
antisepsis, upon rest, upon baths, upon regulation 
diet, and habits of life. 

A number of the more sudden and fatal disturbances 
of the nervous system, as for instance, the familiar 
" stroke of paralysis," or apoplexy, of later middle life, 
are due to a defect, not in the nervous system at all, but 
in the blood-vessels supplying the brain ; rupture of a 
vessel, and consequent escape of blood, destroys so 
much of the surrounding brain-tissue as to produce 
paralysis, and, in extreme cases, death. Just why the 
blood-vessels of the brain in general, and of one part 
of the basal ganglia in particular (the Lenticulo- 
striate artery in the internal capsule of the corpus 


striatum, the old jaw ganglion) , are so liable to rupture 
we do not know; but it certainly is chiefly from a de- 
fect of the blood-vessels, and not of the brain. All of 
which brings us to the following important practical 

First of all, that every attack or touch, however 
light, of "nervousness," "nerves," "imagination," 
" neurasthenia," yes, hysteria, means something. It is 
the cry of protest of a smaller or larger part of the ner- 
vous system against underfed blood, under- ventilated 
muscles, lack of sunlight, lack of exercise, lack of sleep, 
excess of work, or bad habits. In other words, it is the 
danger signal, the red light showing the open switch, 
and we will disregard it at our peril. Unfortunately, by 
that power of esprit de corps of the entire system, known 
as "pluck" or "grit," or the veto-power, physiologi- 
cally termed inhibition, we may ignore and for a time 
suppress the symptom, but this in the long run is just 
as rational as cutting the wire that rings a fire alarm, 
or blowing out the red light without closing the switch. 

Nervousness is a symptom which should always 
have something done for it, especially in children. 
In fact, it has passed into an axiom both with intelli- 
gent teachers and with physicians who have much to 
do with the little ones, that crossness, fretfulness, lazi- 
ness, lack of initiative, and readiness to weep, in chil- 
dren, are almost invariably the signs of physical disease. 
And this doctrine will apply to a considerable percent- 
age of children of larger growth. 

Unfortunately, one of the first and most decided 
tendencies on the part of the badly fed or poisoned ner- 


vous system, is to exaggerate the difficulties of the situ- 
ation, and to minimize its good features. The individ- 
ual " has lost his nerve," is afraid to undertake things, 
shrinks from responsibility, exaggerates the difficulties 
that may be in the way; hence the floods of tears, or 
outbursts of temper, with which nervous children will 
greet the suggestion of any task or duty, however tri- 
fling. If the nervous individual has reached that stage 
of maturity when she realizes that she is not merely 
" naughty," but sick, then this same process applies 
itself to her disease. She is sure that she is going to 
die, that another attack like that will end in paralysis ; 
as a patient of mine once expressed it to me, " My heart 
jumps up in my mouth, I bite a couple of pieces off it, 
and it falls back again." In short, she so obviously 
and grossly exaggerates every symptom and phase of 
her disease, that the impression irresistibly arises that 
the disease itself is a fabrication. This view of her con- 
dition by her family or her physician is the tragedy 
of the neurasthenic. 

Broadly speaking, no disease, even of the nervous 
system, is ever purely imaginary. Some part of the 
patient's nervous system is poisoned, or he would not 
imagine himself to be sick. We can all of us find 
trouble enough in some part of our complex bodily 
machinery, if we go around hunting for it; but this is 
precisely what the healthy man, or woman, never does. 
They have other things to occupy them, and are far 
more liable to run into danger by pushing ahead at full 
steam, and neglecting small creakings and jarrings 
until something important in the gear jams, or goes 


snap, and brings them to a halt, than they are to be 
wasting time and energy worrying over things that 
may never happen. 

Worry, in fact, is a sign of disease instead of a cause. 
To put it very crudely, whenever the blood and fluids of 
a body become impoverished below a certain degree, 
or become loaded with fatigue poisons, or other waste 
products above a certain point, then the nervous system 
proceeds to make itself felt. Either the perceptive end- 
organs become color-blind and read yellow for blue, or 
are astigmatic and report oval for round ; or the con- 
ducting nerve-strands tangle up the messages, or de- 
liver them to the wrong centre ; or the central clearing- 
house, puzzled by the crooked messages, loses its head, 
and begins to throw the inkstands about, or goes down 
in a sulk. In other words, the nervous system goes on 
a strike. But it is perfectly idle to endeavor to treat it 
with cheering words, or kindly meant falsehoods, to 
the effect that " nothing is really the matter." Like any 
other strike, it can be rationally dealt with only by 
improving the conditions under which the operatives 
have to work, and meeting their demands for higher 
wages, or shorter hours. 

We were accustomed at one time to divide diseases 
into two great classes, organic and functional. By the 
former, we meant those in which there was some posi- 
tive defect of structure, which could be recognized by 
the eye or the microscope ; by the latter, those diseases 
in which this could not be discovered, in which, so to 
speak, the machine was all right, but simply would n't 
work. It goes without saying that the latter class was 


simply a confession of our ignorance, and one which 
is steadily and rapidly diminishing as science pro- 

If the machine won't work, there is a reason for it 
somewhere, and our business is to find it out, and not 
loftily to assure our patients that there is nothing 
much the matter, and all they need is rest, or a little 
cheerful occupation. Furthermore, the most inane 
thing that a sympathizing friend or kindly physician 
can do to a neurasthenic, is to advise him to take his 
mind off himself or his symptoms. The utter inability 
to do that very thing is one of the chief symptoms of 
the disease, which will not disappear until the under- 
lying cause has been carefully studied out and removed. 

"Nerves," "neurasthenia," " psychasthenia," and 
"hysteria," are all the names of symptoms of definite 
bodily disease. The modern physician regards it as his 
duty to study out and discover the nature of this dis- 
ease, and, if possible, remove it, rather than to give 
high-sounding, soul-satisfying names to the symptoms, 
and advise the patient to " cheer up " ; which advice 
costs nothing and is worth just what it costs. 

"But," some one will say at once, "if nervous dis- 
eases are simply the reflection of general bodily states, 
as sanitary conditions improve under civilization, 
should they not become less frequent? And yet, any 
newspaper will tell you that nervous diseases are rapidly 
on the increase." This is a widespread belief, not only 
on the part of the public, but of many scientists and a 
considerable number of physicians ; but it is, I believe, 


In the first place, we have no reliable statistical basis 
for a positive statement, either one way or another. 
Our ignorance of the precise prevalence of disease in 
savagery, in barbarism, and even under civilization up 
to fifty years ago, is absolute and profound. It is only 
since 1840 that vital statistics of any value, except as 
to gross deaths and births, began to be kept. So far as 
we are able to judge from our study of savage tribes by 
the explorer, the army surgeon, and the medical mission- 
ary, the savage nervous system is far less well balanced 
and adjustable than that of civilized man. Hysteria, 
instead of occurring only in individual instances, at- 
tacks whole villages and tribes. In fact, the average 
savage lives in a state alternating between naive and 
childish self-satisfaction and panic-stricken terror, with 
their resultant cowardice and cruelty on the one hand, 
and unbridled lust and delusions of grandeur on the 
other. The much-vaunted strain of civilization upon 
the nervous system is not one-fifth that of savagery. 

Think of living in a state when any night might see 
your village raided, your hut burned, yourself killed 
or tortured at the stake, and your wife and children 
carried into slavery. Read the old hymns and see how 
devoutly thankful our pious ancestors were every day 
at finding themselves alive in the morning, " Safely 
through another night," and fancy the nerve-strain 
of never knowing, when you lay down to sleep, whether 
some one of the djinns, or voodoos, or vampires would 
swoop down upon you before morning. Think of 
facing death by famine every winter, by drought or 
cyclone every summer, and by open war or secret scalp- 


raid every month in the year ; and then say that the 
racking nerve-strain of the commuter's time-table, the 
deadly clash of the wheat-pit, or the rasping grind of 
office-hours, would be ruinous to the uncivilized ner- 
vous system. Certainly, in those belated savages, the 
dwellers in our slums, hysteria, diseases of the imagina- 
tion, enjoyment of ill health, and the whole brood of 
functional nervous disturbances are just as common 
as they are on Fifth Avenue. 

It is not even certain that insanity is increasing. In- 
sanity is quite common among savages ; just how com- 
mon is difficult to say, on account of their peculiar 
methods of treating it. The stupid and the dangerous 
forms are very apt to be simply knocked on the head, 
while the more harmless and fantastic varieties are 
turned into priests and prophets and become the 
founders of the earlier religions. A somewhat similar 
state of affairs of course prevailed among civilized 
races up to within the last three-quarters of a century. 
The idiot and the harmless lunatic were permitted to 
run at large, and the latter, as court and village fools, 
furnished no small part of popular entertainment, since 
organized into vaudeville. Only the dangerous or vio- 
lent maniacs were actually shut up ; consequently, the 
number of insane in a community a century ago refers 
solely to this class. Hence, in every country where sta- 
tistics have been kept, as larger and larger percentages 
of these unfortunates have been gathered into hospitals, 
where they can be kindly cared for and intelligently 
treated, the number of the registered insane has steadily 
increased up to a certain point. This was reached some 


fifteen years ago in Great Britain, in Germany, in 
Sweden, and in other countries which have taken the 
lead in asylum reform, and has remained practi- 
cally stationary since, at the comparatively low rate 
of from two to three per thousand living. This limit 
shows signs of having been reached in the United 
States already ; and this gradual increase of recognition 
and registration is the only basis for the alleged increase 
of insanity under modern conditions. 

It is also a significant fact that the lower and less 
favorably situated stratum of our population furnishes 
not only the largest number of inmates, but the largest 
percentage of insanity in proportion to their numbers, 
while the most highly educated and highly civilized 
classes furnish the lowest. Immigrants furnish nearly 
three times as many inmates per thousand to our 
American asylums as the native born. 

It is, however, true that in each succeeding census 
a steadily increasing number and percentage of the 
deaths is attributed to diseases of the nervous system. 
This, however, does not yet exceed fifteen or twenty 
per cent of the whole, which would be, so to speak, 
the natural probable percentage of deaths due to 
failure of one of the five great systems of the body: 
the digestive, the respiratory, the circulatory, the 
glandular, the nervous. Two elements may certainly 
be counted upon as contributing in very large degree 
to this apparent increase. One is the enormous saving 
of life which has been accomplished by sanitation and 
medical progress during the first five years of life, 
infant mortality having been reduced in many instances 


fifty to sixty per cent, thus of course leaving a larger 
number of individuals to die later in life by the diseases 
especially of the blood-vessels, kidneys, and nervous 
system, which are most apt to occur after middle life. 
The other is the great increase in medical knowledge, 
resulting in the more accurate discovery of the causes 
of death, and a more correct reporting and classifying 
of the same. 

In short, a careful review of all the facts available 
to date leads us decidedly to the conclusion that the 
nervous system is the toughest and most resisting 
tissue of the body, and that its highest function, the 
mind, has the greatest stability of any of our bodily 
powers. Only one man in six dies of disease of the ner- 
vous system, as contrasted with nearly one in three 
from diseases of the lungs ; and only one individual in 
four hundred becomes insane, as contrasted with from 
three to ten times that number whose digestive systems, 
whose locomotor apparatus, whose heart and blood- 
vessels become hopelessly deranged without actually 
killing them. 



ONE of the dearest delusions of man through all 
the ages has been that his body is under the 
control of his mind. Even if he did n't quite believe it 
in his heart of hearts, he has always wanted to. The rea- 
son is obvious. The qne thing that he felt absolutely 
sure he could control was his own mind. If he could n't 
control that, what could he control ? Ergo, if man could 
control his mind and his mind could control his body, 
man is master of his fate. Unfortunately, almost in 
proportion as he becomes confident of one link in the 
chain he becomes doubtful of the other. Nowadays 
he has quite as many qualms of uncertainty as to 
whether he can control his mind as about the power 
of his mind over his body. By a strange paradox we 
are discovering that our most genuine and lasting con- 
trol over our minds is to be obtained by modifying the 
conditions of our bodies, while the field in which we 
modify bodily conditions by mental influence is steadily 

For centuries we punished the sick in mind, the in- 
sane, loading them with chains, shutting them up in 
prison-cells, starving, yes, even flogging them. We 
exorcised their demons, we prayed over them, we ar- 
gued with them, without the record of a single cure. 


Now we treat their sick and ailing bodies just as we 
would any other class of chronic patients, with rest, 
comfortable surroundings, good food, baths, and fresh 
air, correction of bad habits, gentleness, and kindness, 
leaving their minds and souls practically without 
treatment, excepting in so far as ordinary, decent hu- 
manity and consideration may be regarded as mental 
remedies, and we cure from thirty to fifty per cent, 
and make all but five per cent comfortable, contented, 
comparatively happy. 

We are still treating the inebriate, the habitual drunk- 
ard, as a minor criminal, by mental and moral means 
with what hopeful results let the disgraceful records 
of our police courts testify. We are now treating tru- 
ancy by the removal of adenoids and the fitting of 
glasses; juvenile crime by the establishment of play- 
grounds; poverty and pauperism by good food, living 
wages, and decent surroundings; and all for the first 
time with success. 

In short, not only have all our substantial and per- 
manent victories over bodily ills been won by physical 
means, but a large majority of our successes in mental 
and moral diseases as well. Yet the obsession persists, 
and we long to extend the realm of mental treatment 
in bodily disease. 

That the mind does exert an influence over the body, 
and a powerful one, in both health and disease, is ob- 
vious. But what we are apt to forget is that the whole 
history of the progress of medicine has been a record 
of diminishing resort to this power as a means of cure. 
The measure of our success and of our control over 


disease has been, and is yet, in exact proportion to the 
extent to which we can relegate this resource to the 
background and avoid resorting to it. Instead of 
mental influence being the newest method of treatment 
it is the oldest. Two-thirds of the methods of the sha- 
man, the witch-doctor, the medicine-man, were 
psychic. Instead of being an untried remedy, it is 
the most thoroughly tested, most universal, most ubi- 
quitous remedy listed anywhere upon the pages of 
history, and, it may be frankly stated, in civilized 
countries, as widely discredited as tested. The pro- 
portion to which it survives in the medicine of any 
race is the measure of that race's barbarism and 
backwardness. To-day two of the most significant 
criteria of the measure of enlightenment and of control 
over disease of either the medical profession of a nation 
or of an individual physician are the extent to which 
they resort to and rely upon mental influence and 
opium. Psychotherapy and narcotics are, and ever 
have been, the sheet-anchors of the charlatan and the 

The attitude of the medical profession toward mental 
influence in the treatment of disease is neither friendly 
nor hostile. It simply regards it as it would any other 
remedial agency, a given drug, for instance, a bath, 
or a form of electricity or light. It is opposed to it, if 
at all, only in so far as it has tested it and found it in- 
ferior to other remedies. Its distrust of it, so far as 
this exists, is simply the feeling that it has toward half 
a hundred ancient drugs and remedial agencies which 
it has dropped from its list of working remedies as 


obsolete, many of which still survive in household and 
folk medicine. My purpose is neither to champion it 
nor to discredit it, and least of all to antagonize or 
throw doubt upon any of the systems of philosophy or 
of religion with which it has been frequently associated, 
but merely to attempt to present a brief outline of its 
advantages, its character, and its limitations, exactly as 
one might of, say, calomel, quinine, or belladonna. 

As in the study of a drug, the chief points to be con- 
sidered are : What are its actual powers ? What effects 
can be produced with it, both in health and sickness ? 
What are the diseases in which such effects may be 
useful, and how frequent are they ? In what way does 
it produce its effects, directly or indirectly ? 

The first and most striking claim that is made for 
mental influence in disease is based upon the allegation 
that it has the power of producing disease and even 
death; the presumption, of course, being that, if able 
to produce these conditions, it would certainly have 
some influence in removing or preventing them. Upon 
this point the average man is surprisingly positive and 
confident in his convictions. Popular literature and 
legend are full of historic instances where individuals 
have not merely been made seriously ill but have even 
been killed by powerful impressions upon their imagi- 
nations. Most men are ready to relate to you instances 
that have been directly reported to them of persons 
who were literally frightened to death. But the mo- 
ment that we come to investigate these widely quoted 
and universally accepted instances, we find ourselves 
in a curious position. On the one hand, merely a 


series of vague tales and stories, without date, lo- 
cality, name, or any earmark by which they can be 
identified or tested. On the other, a collection of rare 
and extraordinary instances of sudden death which 
have happened to be preceded by a powerful mental 
impression, many of which bear clearly upon their 
face the imprint of death by rupture of a blood-vessel, 
heart failure, or paralysis, in the course of some well- 
marked and clearly defined chronic disease, like val- 
vular heart-mischief, diabetes, or Bright 's disease. 

Upon investigation most of these cases which have 
been seen by a physician previous to death have been 
recognized as subjed: to a disease likely to terminate 
in sudden death; and practically all in which a post- 
mortem examination has been made have shown a 
definite physical cause of death. The fright, anger, 
or other mental impression, was merely the last straw, 
which, throwing a sudden strain upon already weak- 
ened vessels, heart, or brain, precipitated the final 
catastrophe. In some cases, even the sense of fright 
and the premonition of approaching death were merely 
the first symptoms of impending dissolution. 

The stories of death from purely imaginative impres- 
sions, such as the victims being told that they were 
seriously ill, that they would die on or about such and 
such a date, fall into two great classes. The first of 
these involving death at a definite date, after it had 
been prophesied either by the victim or some physician 
or priest may be dismissed in a few words, as they 
lead at once into the realm of prophecy, witchcraft, 
and voodoo. Most of them are little better than after- 


echoes of the ethnic stories of the "evil eye," and of 
bewitched individuals fading away and dying after 
their wax image has been stuck full of pins or otherwise 
mutilated. There have occurred instances of individ- 
uals dying upon the date at which some one in whose 
powers of prophecy they had confidence declared they 
would, or even upon a date on which they had settled 
in their own minds, and announced accordingly; but 
these are so rare as readily to come within the percent- 
age probabilities of pure coincidence. Most such pro- 
phecies fail utterly; but the failures are not recorded, 
only the chance successes. 

The second group of these alleged instances of death 
by mental impression is in most singular case. Prac- 
tically every one with whom you converse, every popu- 
lar volume of curiosities which you pick up, is ready to 
relate one or more instances of such an event. But the 
more you listen to these relations, the more familiar do 
they become, until finally they practically simmer 
down to two stock legends, which we have all heard 
related in some form. 

First, and most famous, is the story of a vigorous, 
healthy man accosted by a series of doctors at succes- 
sive corners of the street down which he is walking, 
with the greeting : 

" Why, my dear Mr. So-and-So, what is the matter ? 
How ill you look!" 

He becomes alarmed, takes to his bed, falls into a 
state of collapse, and dies within a few days. 

The other story is even more familiar and dramatic. 
Again it is a group of morbidly curious and spiteful 


doctors who desire to see whether a human being can 
be killed by the power of his imagination. A con- 
demned criminal is accordingly turned over to them. 
He is first allowed to see a dog bled to death, one of 
the physicians holding a watch and timing the process 
with, "Now he is growing weaker! Now his heart is 
failing ! Now he dies ! " Then, after having been in- 
formed that he is to be bled to death instead of guil- 
lotined, his eyes are bandaged and a small, insignificant 
vein in his arm is opened. A basin is held beneath his 
arm, into which is allowed to drip and gurgle water 
from a tube so as to imitate the sounds made by the 
departing life-blood. Again the death-watch is set and 
the stages of his decline are called off: "Now he 
weakens ! Now his heart is failing !" until finally, with 
the solemn pronouncement, " Now he dies ! " he falls 
over, gasps a few times and is dead, though the total 
amount of blood lost by him does not exceed a few 

A variant of the story is that the trick was played for 
pure mischief in the initiation ceremonies of some lodge 
or college fraternity, with the horrifying result that 
death promptly resulted. 

The stories seem to be little more than pure creatures 
of the same force whose power they are supposed to 
illustrate, amusing and dramatic fairy-tales, handed 
down from generation to generation from Heaven 
knows what antiquity. Death under such circumstances 
as these may have occurred, but the proofs are totally 
lacking. One of our leading neurologists, who had ex- 
tensively experimented in hypnotism and suggestion, 


declared a short time ago : " I don't believe that death 
was ever caused solely by the imagination." 

Now as to the scope of this remedy, the extent of the 
field in which it can reasonably be expected to prove 
useful. This discussion is, of course, from a purely phy- 
sical point of view. But it is, I think, now generally 
admitted, even by most believers in mental healing, 
that it is only, at best, in rarest instances that mental 
influence can be relied upon to cure organic disease, 
namely, disease attended by actual destruction of tissue 
or loss of organs, limbs, or other portions of the body. 
This limits its field of probable usefulness to the so- 
called "functional diseases," in which to put it 
crudely the body-machine is in apparently perfect 
or nearly perfect condition, but will not work; and 
particularly that group of functional diseases which is 
believed to be due largely to the influence of the imagi- 

Nowhere can the curious exaggeration and over- 
estimation of the real state of affairs in this field be bet- 
ter illustrated than in the popular impression as to the 
frequency in actual practice of "imaginary" diseases. 
Take the incidental testimony of literature, for instance, 
which is supposed to hold the mirror up to nature, to 
be a transcript of life. The pages of the novel are full, 
the scenes of the drama are crowded with imaginary 
invalids. Not merely are they one of the most valuable 
stock properties for the humorist, but whole stories 
and comedies have been devoted to their exploitation, 
like Moliere's classic "Le Malade Imaginaire," and 
"Le Medecin Malgre Lui." Generation after genera- 


tion has shaken its sides until they ached over these 
pompous old hypochondriacs and fussy old dowagers, 
whose one amusement in life is to enjoy ill health and 
discuss their symptoms. They are as indispensable 
members of the dramatis persona of the stock company 
of fiction as the wealthy uncle, the crusty old bachelor, 
and the unprotected orphan. Even where they are only 
referred to incidentally in the course of the story, you 
are given to understand that they and their kind furnish 
the principal source of income for the doctor; that if 
he has n't the tact to humor or the skilled duplicity to 
plunder and humbug these self-made sufferers, he might 
as well retire from practice. In short, the entire atmo- 
sphere of the drama gives the strong impression that 
if people particularly the wealthy classes would 
shake themselves and go about their business, two-thirds 
of the illness in the world would disappear at once. 

Much of this may, of course, be accounted for by 
the delicious and irresistible attractiveness, for literary 
purposes, of this type of invalid. Genuine, serious ill- 
ness, inseparable from suffering and ending in death, 
is neither a cheerful, an interesting, nor a dramatic 
episode, except in very small doses, like a well-staged 
deathbed or a stroke of apoplexy, and does not furnish 
much valuable material for the novelist or the play- 
writer. Battle, murder, and sudden death, while hor- 
rible and repulsive, can be contemplated with vivid, 
gruesome interest, and hence are perfectly available 
as interest producers. But much as we delight to talk 
about our symptoms, we are never particularly inter- 
ested in listening to those of others, still less in seeing 


them portrayed upon the stage. On account of their 
slow course, utter absence of picturesqueness, and de- 
pressing character, the vast majority of diseases are 
quite unsuitable for artistic material. In fact, the lit- 
erary worker is almost limited to a mere handful, at 
one extreme, which will produce sudden and dramatic 
effects, like heart failure, apoplexy, or the ghastly 
introduction of a "slow decline" for a particularly 
pathetic effect; and at the other extreme, those im- 
aginary diseases, migraines and vapors, which furnish 
amusement by their sheer absurdity. 

Be that as it may, such dramatic and literary ten- 
dencies have produced their effect, and the popular 
impression of the doctor is that of a man w r ho spends 
his time between rushing at breakneck speed to save 
the lives of those who suddenly find themselves in 
articulo mortis and will perish unless he gets there 
within fifteen minutes, and dancing attendance upon a 
swarm of old hypochondriacs, neurotics, and nervous 
dyspeptics, of both sexes. As a matter of fact, these 
two supposed principal occupations of the doctor are 
the smallest and rarest elements in his experience. 

A few years ago a writer of world-wide fame de- 
liberately stated, in the course of a carefully considered 
and critical discussion of various forms of mental heal- 
ing, that it was no wonder that these methods excited 
huge interest and wide attention in the community, 
because, if valid, they would have such an enormous 
field of usefulness, seeing that at least seven-tenths 
of all the suffering which presented itself for relief to 
the doctor was imaginary. 


This, perhaps, is an extreme case, but is not far from 
representing the general impression. If a poll were to 
be taken of five hundred intelligent men and women 
selected at random, as to how much of the sufferings of 
all invalids, or sick people who are not actually ob- 
viously "sick unto death" or ill of a fever, was real 
and how much imaginary, the estimate would come 
pretty close to an equal division. But when one comes 
to try to get at the actual facts, an astonishingly differ- 
ent state of affairs is revealed. I frankly confess that 
my own awakening was a matter of comparatively 
recent date. 

A friend of mine was offered a position as consulting 
physician to a large and fashionable sanatorium. He 
hesitated because he was afraid that much of his time 
would be wasted in listening to the imaginary pains, 
and soothing the baseless terrors, of wealthy and fash- 
ionable invalids, who had nothing the matter with 
them except in the language of the resort " ner- 
vous prosperity." His experience was a surprise. At 
the end of two years he told me that he had had under 
his care between six and seven hundred invalids, a 
large percentage of whom were drawn from the wealth.- 
ier classes; and out of this number there were only 
jive whose sufferings were chiefly attributable to their 
imagination. Many of them, of course, had compara- 
tively trivial ailments, and others exaggerated the de- 
gree or mistook the cause of their sufferings; but the 
vast majority of them were, as he naively expressed it, 
"really sick enough to be interesting." 

This set me to thinking, and I began by making a 


list of all the "imaginary invalids" I had personally 
known, and to my astonishment raked up, from over 
twenty years' medical experience, barely a baker's 
dozen. Inquiries among my colleagues resulted in a 
surprisingly similar state of affairs. While most of 
them were under the general impression that at least 
ten to twenty per cent of the illnesses presenting them- 
selves were without substantial physical basis and 
largely imaginary in character, when they came actually 
to cudgel their memories for well-marked cases and to 
consult their records, they discovered that their memo- 
ries had been playing the same sort of tricks with them 
that the dramatists and novelists had with popular 

Within the past few months one of the leading 
neurologists of New York, a man whose practice is 
confined exclusively to mental and nervous diseases, 
stated in a public address that purely or even chiefly 
imaginary diseases were among the rarer conditions 
that the physician was called upon to treat. Shortly 
after, two of the leading neurologists of Philadelphia, 
one of them a man of international reputation, practi- 
cally repeated this statement ; and they put themselves 
on record to the effect that the vast majority of those 
who imagined themselves to be ill were ill, though 
often not to the degree or in precisely the manner that 
they imagined themselves to be. 

Obviously, then, this possible realm of suffering in 
which the mind can operate is very much more limited 
than was at one time believed. In fact, imaginary dis- 
eases might be swept out of existence, and humanity 


would scarcely know the difference, so little would 
the total sum of its suffering be reduced. 

Another field in which there has been much general 
misunderstanding and looseness of both thought and 
statement, which has again led to exaggerated ideas 
of the direct influence of the mind over the body, is 
the well-known effect of emotional states, such as 
fright or anger, upon the ordinary processes of the 
body. Instances of this relation are, of course, house- 
hold words, the 'man whose " hair turned white in 
a single night" from grief or terror; the nursing mother 
who flew into a furious^fit of passion and whose child 
was promptly seized with convulsions and died the 
next time it was put to the breast; the father who is 
prostrated by the death or disgrace of a favorite son, 
and dies within a few weeks of a broken heart. The 
first thing that is revealed by even a brief study of this 
subject is that these instances are exceedingly rare, and 
owe their familiarity in our minds to their striking and 
dramatic character and the excellent " material " which 
they make for the dramatist and the gossip. It is even 
difficult to secure clear and valid proof of the actual 
occurrence of that sudden blanching of the hair, which 
has in the minds of most of us been accepted from our 
earliest recollection. 

More fundamental, however, and vital, is the extent 
to which we have overlooked the precise method in 
which these violent emotional impressions alter bodily 
activities, like the secretions. Granting, for the sake 
of argument, that states of mind, especially of great 
tension, have some direct and mysterious influence as 


such, and through means which defy physical recog- 
nition and study, it must be remembered that they 
have a perfectly definite physiological sphere of influ- 
ence upon vital activities. Indeed, we are already in 
a position to explain at least two-thirds of these so- 
called "mental influences" upon purely physical and 
physiological grounds. 

First of all, we must remember that these emotions 
which we are pleased to term "states of mind" are 
also states of body. If any man were to stand up before 
you, for instance, either upon the stage or in private, 
and inform you that he was " scared within an inch of 
his life," without tremor in his voice, or paling of his 
countenance, or widening eyes, or twitching muscles, 
or preparations either to escape or to fight, you would 
simply laugh at him. You would readily conclude, 
either that he was making fun of you and felt no such 
emotion, or that he was repressing it by an act of mi- 
raculous self-control. The man who is frightened and 
does n't do anything or look as if he were going to do 
anything, the man who is angry and makes no move- 
ment or even twitching suggesting that fact, is neither 
angry nor frightened. 

An emotional state is, of course, a peculiarly com- 
plex affair. First, there is the reception of the sensa- 
tion, sight, sound, touch, or smell, which terrifies. 
This terror is a secondary reaction, and in ninety-nine 
cases out of a hundred is conditioned upon our mem- 
ory of previous similar objects and their dangerousness, 
or our recollection of what we have been told about their 
deadliness. Then instantly, irrepressibly, comes the 


lightning-flash of horror to our heart, to our muscles, 
to our lungs, to get ready to meet this emergency. 
Then, and not till then, do we really feel the emotion. 
In fact, our most pragmatic philosopher, William 
James, has gone so far as to declare that emotions are 
the after-echoes of muscular contractions. By the 
time an emotion has fairly got us in its grip so that we 
are really conscious of it, the blood-supply of half the 
organs in our body has been powerfully altered, and 
often completely reversed. 

To what extent muscular contractions condition 
emotions, as Professor James has suggested, may be 
easily tested by a quaint and simple little experiment 
upon a group of the smallest voluntary muscles in the 
body, those that move the eyeball. Choose some time 
when you are sitting quietly in your room, free from all 
disturbing thoughts and influences. Then stand up and, 
assuming an easy position, cast the eyes upward and 
hold them in that position for thirty seconds. Instantly 
and involuntarily you will be conscious of a tendency 
toward reverential, devotional, contemplative ideas 
and thoughts. Then turn the eyes sideways, glancing 
directly to the right or to the left, through half-closed 
lids. Within thirty seconds images of suspicion, of 
uneasiness, or of dislike, will rise unbidden in the mind. 
Turn the eyes to one side and slightly downward, and 
suggestions of jealousy or coquetry will be apt to spring 
unbidden. Direct your gaze downward toward the 
floor, and you are likely to go off into a fit of reverie 
or of abstraction. 

In fact, as Darwin long ago remarked, quoting in 


part from Bain: "Most of our emotions [he should 
have said all] are so closely connected with their ex- 
pression that they hardly exist if the body remains 
passive. As Louis XVI, facing a mob, exclaimed, 
'Afraid? Feel my pulse!' so a man may intensely 
hate another, but until his bodily frame is affected 
he can hardly be said to be enraged." 

And, a little later, from Maudsley: 

"The specific muscular action is not merely an ex- 
ponent of passion, but truly an essential part of it. 
If we try, while the features are fixed in the expression 
of one passion, to call up in the mind a different one, 
we shall find it impossible to do so." 

It will also be recollected what an important part 
in the production of hypnosis and the trance state, fixed 
and strained positions of these same ocular muscles 
have always been made to play. Many hypnotists can 
bring their subjects under their influence solely by 
having them gaze fixedly at some bright object like a 
mirror, or into a crystal sphere, for a few minutes or 
even seconds. 

A graphic illustration of the importance of muscu- 
lar action in emotional states is the art of the actor. 
Not only would it be impossible for an actor to make 
an audience believe in the genuineness of his supposed 
emotion if he stood glassy-eyed and wooden-limbed 
declaiming his lines in a monotone, without gestures 
or play of expression of any sort, but it would also be 
impossible for him to feel even the counterfeit sensa- 
tion which he is supposed to represent. So definite and 
so well recognized is this connection, that many actors 


take some little time, as they express it, to " warm up " 
to their part, and can be visibly seen working themselves 
up to the pitch of emotion desired for expression by 
twitching muscles, contractions of the countenance, 
and catchings of the breath. This last performance, 
by the way, is not by any means confined to the stage, 
but may be seen in operation in clashes and disagree- 
ments in real life. An individual who knows his 
case to be weak, or himself to be lacking in determina- 
tion, can be seen working himself up to the necessary 
pitch of passion or of obstinacy. There is even a lovely 
old fairy-tale of our schoolboy days, which is still to 
be found in ancient works on natural history, to the 
effect that the King of Beasts himself was provided 
with a small, horny hook or spur at the end of his tail, 
with which he lashed himself into a fury before spring- 
ing upon his enemy! 

What, then, will be the physical effect of a shock or 
fright or furious outburst of anger upon the vital se- 
cretions ? Obviously, that any processes which require 
a full or unusually large share of blood-supply for their 
carrying out will be instantly stopped by the diversion 
of this from their secreting cells, in the wall of the 
stomach, in the liver, or in the capillaries of the brain, 
to the great muscular masses of the body, or by some 
strange, atavistic reflex into the so-called "abdominal 
pool," the portal circulation. The familiar results are 
just what might have been expected. The brain is so 
suddenly emptied of blood that connected thought 
becomes impossible, and in extreme cases we stand as 
one paralyzed, until the terror that we would flee from 


crashes down upon us, or we lose consciousness and 
swoon away. If the process of digestion happens to be 
going on, it is instantly stopped, leaving the food to 
ferment and putrefy and poison the body-tissues which 
it would otherwise have nourished. The cells of the 
liver may be so completely deprived of blood as to stop 
forming bile out of broken-down blood pigment, and 
the latter will gorge every vessel of the body and escape 
into the tissues, producing jaundice. 

Every one knows how the hearing of bad news or 
the cropping up of disagreeable subjects in conversa- 
tion at dinner-time will tend to promote indigestion in- 
stead of digestion. The mechanism is precisely similar. 
The disagreeable news, if it concern a financial or ex- 
ecutive difficulty, will cause a rush of blood to the brain 
for the purpose of deciding what is to be done. But 
this diminishes the proper supply of blood to the stom- 
ach and to the digestive glands, just as really as the 
paralysis of violent fright or an explosion of furious 
anger. If the unpleasant subject is yet a little more 
irritating and personal, it will lead to a corresponding 
set of muscular actions, as evidenced in heightened 
color, loud tones, more or less violent gesticulation, 
with marked interruption of both mastication and the 
secretion of saliva and all other digestive juices. In 
short, fully two-thirds of the influences of emotional 
mental states upon the body are produced by their 
calling away from the normal vital processes the blood 
which is needed for their muscular and circulatory 
accompaniments. No matter how bad the news or how 
serious the danger, if they fail to worry us or to frighten 


us, in other words, to set up this complicated train 
of muscular and blood-supply changes, then they 
have little or no effect upon our digestions or the me- 
tabolism of our liver and kidneys. 

The classic "preying upon the damask cheek" of 
grief, and the carking effect of the Black Care that rides 
behind the horseman, have a perfectly similar physical 
mechanism. While the primary disturbance of the 
banking balances of the body is less, this is continued 
over weeks and months, and in addition introduces 
another factor hardly less potent, by interfering with all 
the healthful, normal, regular habits of the body, 
appetite, meal- times, sleep, recreation. These wastings 
and pinings and fadings away are produced by mental 
influence, in the sense that they cannot be cured by 
medicines or relieved at once by the best of hygienic 
advice ; but it is idle to deny that they have also a broad 
and substantial physical basis, in the extent to which 
states of emotional agony, despair, or worry interfere 
with appetite, sleep, and proper exercise and recreation 
in the open air. Just as soon as they cease to interfere 
with this normal regularity of bodily functions, the 
sufferer begins to recover his health. 

We even meet with the curious paradox of individuals 
who, though suffering the keenest grief or anxiety over 
the loss or serious illness of those nearest or dearest to 
them, are positively mortified and ashamed because 
their countenances show so little of the pallid hues and 
the haggard lines supposed to be inseparably associated 
with grief. So long as the body-surplus is abundant 
enough to stand the heavy overdrafts made on it by 


grief and mental distress, without robbing the stomach 
of its power to digest and the brain of its ability to sleep, 
the physical effects of grief, and even of remorse, will 
be slight. 

It must be remembered that loss of appetite is not 
in itself a cause of trouble, but a symptom of the stom- 
ach's inability to digest food ; in this instance, because 
it finds that it can no longer draw upon the natural 
resources of the body in sufficient abundance to carry 
out its operations. The state is exactly like a tightness 
of the money market, when, on account of unnatural 
retention or hoarding in some parts of the financial 
field, the accumulation of sufficient amounts of float- 
ing capital at the banks for moving the crop or paying 
import duties cannot be carried out as usual. The vital 
system is, in fact, in a state of panic, so that the stomach 
cannot get the temporary credit or capital which it 
requires . 

A similar condition of temporary panic, call it mental 
or bodily, as you will, occurs in disease and is not con- 
fined to the so-called imaginary diseases, or even to the 
diseases of the nervous system, but is apt to be present 
in a large number of acute affections, especially those 
attended by pain. Sudden invasion of the system by the 
germs of infectious diseases, with their explosions of 
toxin-shells all through the redoubts of the body, often 
induces a disturbance of the bodily balance akin to 
panic. This is usually accompanied and aggravated by 
an emotional dread and terror of corresponding inten- 
sity. The relief of the latter, by the confident assur- 
ance of an expert and trusted physician that the chances 


are ten to one that the disease will run its course in a 
few days and the patient completely recover, es- 
pecially if coupled with the administration of some 
drug which relieves pain or diminishes congestion in 
the affected organs, will often do much toward re- 
storing balance and putting the patient in a condition 
where the natural recuperative powers of the system 
can begin their work. The historic popularity of opium, 
and of late of the coal-tar products (phenacetine and 
acetanilide) , in the beginning of an acute illness, is 
largely based on the power which they possess of dull- 
ing pain, relieving disturbances of the blood-balance, 
and soothing bodily' and mental excitement. Fever- 
panic or pain-panic, like a banking panic, though it 
has a genuine and substantial basis, can be dealt with 
and relieved much more readily after checking ex- 
cessive degrees of distrust and excitement. An opiate 
will relieve this physical pain-panic, just as a strong 
mental impression will relieve the fright-paralysis and 
emotional panic which often accompany it, and thus 
give a clearer field and a breathing space for the more 
slowly acting recuperative powers of nature to assert 
their influence and get control of the situation. 

But neither of them will cure. The utmost that they 
can do is to give a breathing spell, a lull in the storm, 
which the rallying powers of the body, if present, can 
take advantage of. If the latter, however, be not ade- 
quate to the situation, the disease will progress to 
serious or even fatal termination, just as certainly as 
if no such influence had been exerted, and often at an 
accelerated rate. In fact, our dependence upon opiates 


and mental influence have been both a characteristic 
and a cause of the Dark Ages of medicine. The more 
we depended upon these, the more content we were 
to remain in ignorance of the real causes of disease, 
whether bodily or mental. 

The second physical effect produced by mental in- 
fluence is probably the most important of all, and that 
is the extent to which it induces the patient to follow 
good advice. We as physicians would be the last to 
underestimate the importance of the confidence of our 
patients. But we know perfectly well that our retention 
of that confidence will depend almost entirely upon the 
extent to which we can justify it; that its principal 
value to us lies in the extent to which it will insure 
prompt obedience to our orders, and intelligent and 
loyal cooperation with us in our fight against disease. 
The man who would depend upon the confidence of 
his patients as a means of healing, would soon find 
himself without practice. We know by the bitterest of 
experience that no matter how absolute and boundless 
the confidence of our patients may be in our ability 
to heal them, no matter how much they may express 
themselves as cheered and encouraged by our presence, 
ninety-nine per cent of the chance of their recovery de- 
pends upon the gravity of the disease, the vigor of their 
powers of resistance, and our skill and intelligence in 
combating the one and assisting the other. 

Valuable and helpful as courage and confidence in 
the sick-room are, they are but a broken reed which will 
pierce the hand of him who leans upon it too heavily, 
be he patient or physician. We can all recall, as among 


our saddest and most heart-breaking experiences, the 
cases of fatal disease, which were well-nigh hopeless 
from the start, and yet in which the sufferers expressed, 
and maintained to the last moments of conscious speech, 
a bright and pathetically absolute confidence in our 
powers of healing, based upon our success in some 
previous case, or upon their own irrepressible hope- 

Even the deadliest and most serious of infectious 
diseases, consumption, has as is well known as 
one of its prominent symptoms an irrepressible hope- 
fulness and confidence that they will get well, on the 
part of a considerable percentage of its victims. This 
has even been formally designated in the classical 
medical treatises as the " Spes Phthisical or "Con- 
sumptive Hope." But these hopeful consumptives die 
just as surely as the depressed ones ; in fact, if anything, 
in a little larger proportion. It well illustrates the other 
side of the shield of hope and confidence, the danger 
of unwavering expectancy, in that it is chiefly those 
who are early alarmed and turn vigorously to fight 
the disease under intelligent medical direction, who 
make the recoveries. Too serene a courage, too pro- 
found a confidence in occult forces, is only a form of 
fatalism and a very dangerous one. 

Broadly speaking, mental states in the sick-room 
are a pretty fair index I don't mind saying, prod- 
uct of bodily states. Hopefulness and confidence 
are usually favorable signs, for the reason that they 
are most likely to be displayed by individuals who, al- 
though they may be seriously ill, are of good physique, 


have high resisting power, and will make a successful 
fight against the disease. So, roughly speaking, cour- 
age and hopefulness are good omens, on purely physi- 
cal grounds. 

But these are only rough indications of probabili- 
ties, not reliable signs ; and as a rule we are but little 
affected by either the hopes or the fears of our patients 
in making up our estimate of their chances. The only 
mental symptom that weighs heavily with us is indif- 
ference. This puts us on the lookout at once. So long 
as our patients have a sufficiently vivid and lively fear 
of impending death, we feel pretty sure that they are 
not seriously ill ; but when they assure us dreamily that 
they " feel first-rate," forget to ask us how they are 
getting along, or become drowsily indifferent to the 
outlook for the future, then we redouble our vigilance, 
for we fear that we recognize the gradual approach of 
the Great Restbringer, the merciful drowsiness which 
in nine cases out of ten precedes and heralds the coming 
of the Long Sleep. 

Lastly, the cases in which the sufferings of the patient 
are due chiefly to a morbid action of his or her imagi- 
nation, are a small percentage of the total of the ills 
which come before us for relief. But, even of this 
small percentage, only a very few are in perfect or even 
reasonably good physical health. A large majority of 
even these neurasthenics, psychasthenics, imaginary 
invalids, and bodily or mental neurotics, have some phy- 
sical disturbance, organic or functional, which is the 
chief cause of their troubles. And the important point 
is that our success in relieving these sufferers will de- 


pend upon our skill in ferreting out this physical basis, 
and the extent to which we can succeed in correcting 
or relieving it. We no longer ridicule or laugh at these 
unfortunates. On the contrary we pity them from the 
bottom of our hearts, because we know that their suf- 
ferings, however polarly remote they may be from 
endangering their lives in any way, and however imagi- 
nary in a purely material sense, are to them real. Their 
happiness is destroyed and their efficiency is crippled 
just as genuinely and effectively as if they had a broken 
limb or a diseased heart. 

We are now more and more firmly convinced that 
these patients, however ludicrously absurd their fore- 
bodings, are really sick, either bodily or mentally, 
and probably both. A perfectly healthy individual 
seldom imagines himself or herself to be ill. And as the 
list of so-called functional diseases that is to say, 
those diseases in which no definite, objective mark of 
degeneration or decay in any tissue or organ can be 
discovered are steadily and swiftly diminishing 
under the scrutiny of the microscope and the methods 
of the laboratory, so these purely imaginary diseases, 
these " depressed mental states," these "essential mor- 
bid tendencies," are also rapidly diminishing in num- 
ber, as cases are more conscientiously and personally 
studied and worked out. 

Even hysteria is no longer looked upon as sheer per- 
versity on the part of the patient, but is patiently traced 
back, stage by stage, until if possible the primary 
"strangulated emotion" which caused it is discovered; 
and where this can be found the whole morbid ten- 


dency can often be relieved and reversed Almost as if 
by magic. 

To sum up : My contention is, that the direct influ- 
ence of emotional states upon bodily organs and func- 
tions has been greatly exaggerated ; that it is exceedingly 
doubtful whether, for instance, any individual in a 
reasonable condition of health was ever killed by an 
imaginary or even an emotional shock; that there is 
surprisingly little valid evidence that the hair of any 
human being turned white in a single night, or was 
completely shed within a few hours, under the influ- 
ence of fright, terror, or grief; that the effects upon 
bodily functions and secretions, digestion, etc., pro- 
duced by emotion, are due to secondary effects of the 
latter, diverting the energy of the body into other 
channels and disturbing the general balance of its 
forces and blood-supply ; that the actual percentage of 
cases in which the imagination plays the chief, or even 
a dominant part, is small, probably not to exceed five 
or ten per cent; that a very considerable share of the 
influence of mental impressions in the cure of disease 
is due to the relief of mental panic, permitting the 
rallying of the recuperative powers of the body, and 
to the extent to which they produce the reform of bad 
physical habits or surroundings or conditions. 

The most important element in the cure of disease 
by mental impression is time plus the vis medicatrix 
naturce. The mental impression suggestion, scold- 
ing, securing of confidence diverts the attention of 
the patient until his own recuperative power and the 
intelligent correction of bad physical habits remedy 



his defect. Pure mental impression, however vivid, 
which is not followed up by improvement of the en- 
vironment, or correction of bad physical habits, will 
be almost absolutely sterile. Faith without works 
is as dead in medicine as in religion. Mental influence 
is little more than an introduction committee to real 
treatment. Even the means used for producing mental 
impressions are physical, impressions made upon 
some one of the five senses of the individual. In short, 
as Barker aptly puts it, " Every psychotherapy is also 
a physical therapy." 

Furthermore, even mental worry, distress, or de- 
pression, in nine cases' out of ten has a physical cause. 
To remedy conditions of mental stress by correcting 
the underpay, overwork, bad ventilation, or under- 
feeding on account of illness or death of the wage- 
earner of the family, is, of course, nothing but the most 
admirable common sense; but to call it the mental 
treatment of disease is a mere juggling with words. 
" Take care of the body and the mind will take care of 
itself," is a maxim which will prove valid in actual 
practice nine times out of ten. 



Acne, 38. 

Acromegaly, 119. 

Adenoids, 105-122. 

Air, foul, 97. 

Alimentary canal, 274-279. 

Allbutt, Sir Clifford, 134. 

Allen, Dr. Harrison, 120. 

Animals, immune to certain dis- 
eases, 255. 

Anti-bodies. See Antitoxins. 

Antisepsis, 333, 336-339. 

Antitoxins, or anti-bodies, &, 93, 
94, 199, 200 ; discovery and use 
of the diphtheria antitoxin, 
230-233, 236, 242, 401; te- 
tanus antitoxin, 345, 346, 398. 

Apoplexy, 40, 402. 

Appendicitis, 269-288. 

Appendix, vermiform, 35, 36, 
268-270, 273-279. 

Asepsis, 333. 

Asthmatics, 328. 

Attitude, the upright, 76. 

Autointoxication, 376. 

Bacilli. See Bacteria. 

Bacteria, abundance of, in the 

body, 10, 99. 
Bang, Professor, 148. 
Bath, the cold, 98. 
Bile, in vomiting, 379. 
Bites, danger from, 342. 
Blood, coagulation of, 39, 40. 
Blood-corpuscles, 24-29. 
Blood-poisoning, 331-349. 
Bloodgood, Dr. J. C., 272. 
Bones, nature of, 20, 21. 
Boswell, James, 88. 
Bridge, Dr. Norman, 95. 

Caecum, 274-278. 

Cancer, a rebellion of the cells, 

42, 351 ; heredity and, 50, 51 ; 
individuality of, 350 ; probable 
nature of, 351 ; death-rate from, 
352, 353; natural history of, 
353-364 ; not communicable, 
357, 358; vain search for a 
parasite, 359, 360 ; a disease of 
senility, 363, 364 ; problems of 
prevention and cure, 365, 366. 

Carriage, in illness, 76. 

Cattani, 398. 

Cellular theory of disease, 18, 19. 

Cerebro-spinal meningitis, 397. 

Chantemesse, 221. 

Children's diseases, importance 
of, 243-245; prevention of, 
245 ; dangerous results of, 245, 
246; effect on growth and de- 
velopment, 247; reasons for, 
248-250 ; occasional severity 
of, 251-254; taming of, 253, 
254; causes of, 254, 255; treat- 
ment of, 255, 256; symptoms 
of, 256, 257; the three chief, 

Cities, disease and death-rate in, 

Civilization, and nervousness, 

Cleanliness, 98. 

Cohnheim, 364. 

Colds, treatment of, 11, 12, 93- 
101; cause of, 85-93; how to 
catch, 101, 102; their relation 
to rheumatism, 320, 321, 323, 
324, 326, 327. 

Colic, 4. 

Color, in diagnosis, 70-74. 

Congenital disease, 44, 45. 

Coughing, use of, 11, 12. 

Darwin, Charles, quoted, 425, 



Diagnosis, 55-82. 

Diarrhoea, use of, 5 ; treatment of, 

Diphtheria, 222-242; attacking 
the nervous system, 400, 401. 

Disease, causes of, 3; not abso- 
lute but relative, 14 ; former 
conceptions of, 15-18; organic 
and functional, 405,406; men- 
tal influence in, 411-437. 

Drafts, 94, 95, 99. 

Earache, 110. 
Edison, Thomas A., 286. 
Epilepsy, heredity and, 52, 53. 
Erysipelas, 348. 
Eustachian tubes, 109, 110. 
Expectoration, 142, 143. 
Eye-strain, 377. 

Facial expression, in diagnosis, 

Fever, meaning of, 7, 8; treat- 
ment of, 8-11. 

Flick, Dr. Laurence, 96. 

Fly, house, and typhoid, 210, 211. 

Food-tube, the, 274-279. 

Gait, in illness, 76-78. 

Gall-bladder, 37. 

Grip, the, 90. 

Guinea-pig, a burnt offering, 
222; used in the discovery of 
the diphtheria antitoxin, 229- 

Hand, the, in diagnosis, 73-75. 

Harelip, 37. 

Headache, purpose and meaning 
of, 12, 13, 367-376 ; treatment 
of, 370, 371, 381-386; from 
eye-strain, 377, 386; from di- 
gestive disturbances, 377, 378 ; 
sick headache, 378, 379, 381; 
from stuffy rooms, 380; from 
sluggish bowels and kidney 
trouble, 380 ; from loss of sleep, 
380, 381 ; from nasal obstruc- 
tion, 381 ; rest the cure for, 382- 
384 ; massage for the relief of, 

385, 386 ; the nerves affected in, 

385, 386. 
Heart, effect of rheumatism on, 

314, 315. 
Heredity, in health and disease, 

Hernia, 36. 

Holmes, Oliver Wendell, 125. 
Horses, and disease, 344, 345. 
Hospitals, blood-poisoning and 

antisepsis in, 335-339. 
Humoral theory of disease, 17, 18. 
Huxley, Thomas Henry, quoted, 

1, 112, 201. 
Hysteria, 403, 406, 407, 435. 

Imaginary illness, 415-422, 436. 

Immunity, 93. 

Indians, epidemics among, 251, 

Indifference of the dying, 434. 

Infants, diagnosis in the case of, 
81, 82. 

Influenza, 90. 

Insanity, heredity and, 52-54; 
among savages and in civiliza- 
tion, 408, 409; treatment of, 
411, 412. 

Intestines, 274. 

James, William, 425. 
Johnson, Samuel, 89. 
Joints, diseases of, 318, 319. 

King, Dr. Albert F. A., 298. 
Koch, Robert, 126, 152, 153, 155, 
156, 228, 308. 

Laveran, 295. 
Lister, Lord, 332. 
Liver, functions of, 6, 7. 
Lockjaw, 344-346, 397, 398. 
Locomotor ataxia, 399; diagnosis 

of, 77, 78. 
Lungs, their liability to disease, 

Lupus, 126. 

Malaria, 289-310. 
Measles 243, 246, 248-252, 260- 



Medicines, repulsive, 17. 
Meningitis, 399, 400. See also 

Cerebro-spinal meningitis. 
Mental influence in disease, 411- 


Metschnikoff, Elie, 214. 
Meyer, William, 105. 
Mind, its relation to the body, 

390, 391, 411-437. 
Mosquitoes, and malaria, 297- 


Mouth-breathing, 103-119. 
Moxon, the pathologist, 187. 
Mumps, 252. 

Nails, the, in disease, 74, 75; 
pus-germs lurking under, 334, 
336, 349. 

Nature, as a physician, 2, 3; not 
to be trusted too blindly* 1 7; 
cooperating with, 9. 

Nerves, affected in headache, 
385, 386; old notions of, 387, 
388; reality of, 389, 390; func- 
tion of, 390 ; their diseases due 
to morbid changes in their tis- 
sues, 391, 392; affected by the 
bodily condition, 393-395 ; 
causes of disturbances in, 395- 
397; diseases that attack them 
directly, 397, 398; late effects 
of other diseases on, 398-401 ; 
nervousness and, 401-408 ; 
death-rate from diseases of, 
409, 410. 

Nervousness, 403-408. 

Neurasthenia, 401, 402. 

Nocard, the veterinary patholo- 
gist, 157. 

Northrup, Dr. William, 196. 

Noses, narrow, 118, 119. 

Operations. See Surgery. 
Opiates, 431, 432. 
Osier, Dr. William, 160, 282. 
Ovariotomy, 336. 

Pain, nature's command to halt, 
13, 382; nature's automatic 
regulator, 383. 

Paresis, 399. 

Pimples, 38. 

Pituitary body, 119. 

Pneumonia, cause of, 84, 85, 88, 
178-183, 185, 186 ; easily recog- 
nized, 174, 175 ; recent increase 
of, 184, 186; habits of the 
pneumococcus, 186-191 ; its re- 
lations to age and to other dis- 
eases, 192-194; symptoms of, 
194, 195; treatment of, 195, 
196; outlook as to, 196, 197. 

Poisons in the body, elimination 
of, 3-13; from fatigue, 373- 

Psychotherapy, 413. 

Pus, 331-336; germs of, 339-344, 

Pyaemia, 346. 

Quinine, 293, 294. 

Repair of the body in the lower 

animals, 41, 42. 
Rheumatism, 311-330. 
Ross, Dr. Ronald, 247. 

Savages, nervousness among, 407, 


Scarlet fever, 243, 247, 257-260. 
Sciatica, cure of a case of, 389, 


Sclerosis, lateral, 399. 
Scrofula, 126. 
Seasickness, 379. 
Senn, Dr. Nicholas, 357. 
Septicaemia, 346. 
Sleeping porches, 96, 97. 
Smallpox, 125, 255. 
Smell, 111. 
Spitting, 142, 143. 
Staphylococcus, 339, 340, 343, 

348. See also Pus. 
Sticking-plaster, 343. 
Stomach, 274. 
Streptococcus, 339-341, 348. See 

also Pus. 
Surgery, and blood-poisoning, 

Syphilis congenital 44; organ- 



ism of, -255, 399; attacking the 
nervous system, 399. 

Tait, Lawson, 336. 

Taste, 111. 

Teeth, crowded, 114, 115. 

Tetanus, 344-346, 397, 398. 

Tonsillitis, 320, 323, 324. 

Tonsils, 107-109, 116-118. 

Tooth, wisdom, 36, 37. 

Tuberculosis, congenital, 45 ; 
seeming inheritance of, 46-50 ; 
diagnosis of, 68, 72; discovery 
of the bacterial nature of, 123- 
126; means of fighting, 127, 
128; treatment of, 129-132; 
prevention of, 132, 135-139; 
universality of, 133, 134; pre- 
vention of transmissionlof, 140- 
145; in cattle and other ani- 
mals, 146, 158; encouraging 
outlook as to, 159-166; civili- 
zation and, 166-173 ; cerebral 
complications from, 399 ; hope- 
fulness in, 433. 

Tumor, Jensen's, 358, 362. 

Typhoid fever, 199-221. 
Typhus, 203, 204. 

Uric acid, 327, 328. 

Vestigia, 35-39, 268, 260. 
Virchow, Rudolf, 18. 
Vis medicatrix naturae, 2. 
Voice, in diagnosis, 78. 
Voltaire, on doctors, 14. 
Vomiting, use of, 4, 5; from 

headache and seasickness, 378, 

379; bile in, 379. 

Waters, mineral, 17. 
Whooping-cough, 244, 246, 249, 


Williams, Dr. Leonard, 93. 
Williams, Dr. Roger, 364. 
Wound-fever, among soldiers, 

Wounds, healing of, 40, 41; 

blood-poisoning in, 331-335, 

341-344; treatment of, 342- 

344, 346. 
Wright, Dr., 221. 


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